Académique Documents
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in cardiovascular care
A toolkit for health professionals
2011 National Heart Foundation of Australia ABN 98 008 419 761
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ISBN: 978-1-921748-62-2
PRO-123
Suggested citation: National Heart Foundation of Australia (Aslani P, Krass I, Bajorek B, Thistlethwaite J,
Tofler G on behalf of the Heart Foundation Pharmaceutical Roundtable). Improving adherence in
cardiovascular care. A toolkit for health professionals. 2011.
Disclaimer: This document has been produced by the National Heart Foundation of Australia for the
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Contents
2 Acknowledgements
3 Introduction
cardiovascular medicines.
Learning outcomes
By the end of this module, you will be able to:
1: Adherence to cardiovascular medicines the principles
Module
Consequently, patients may have uncontrolled
Facilitator notes conditions that cause overall poorer health
Adherence
The father of medicine, Hippocrates (c. 460370),
told physicians to keep watch for that fault Adherence can be summarised as the
in patients which makes them lie about the extent to which a persons behaviour
things prescribed.7,8 taking medication, following a diet, and/or
executing lifestyle changes corresponds
Non-adherence to cardiovascular medicines has
with agreed recommendations from a
become a large burden on the healthcare system
healthcare provider.12
budget, as 30% of all prescriptions dispensed
in community pharmacies are for CVD, with In short, rather than obeying, patients
20% being for hypertension.9 However, patient collaborate with their health professionals.
adherence to cardiovascular medicines ranges
from 11 to 83%, depending on the condition being
treated and medicine type.10
continuance and treatment discontinuation, educate patients about their treatment options
have also been used to describe medicine- (e.g. risks and benefits), in a way that they
taking behaviour. can comprehend
help patients make a treatment decision,
The importance and impact of patient non-
1: Adherence to cardiovascular medicines the principles
Activity
Divide participants into small groups. Ask them
2. Therapeutic alliance
to discuss the concept of shared decision making
and identify the pros and cons of involving This refers to the relationship between
patients in their own healthcare, specifically health professionals and patients, as well
in making decisions about their treatment. as between health professionals.
Feedback Its goal is to provide best practice through
Ask groups to give feedback about the pros the establishment of optimal treatment plans
and cons of shared decision making, and what and ongoing support to follow these plans.
this means in their day-to-day practice. We have extended the notion of therapeutic
alliance to include concordance in
interprofessional collaborations between
For patients to be adherent to their medicines, they health professionals.
must be competent and motivated to do so. Therefore,
patient beliefs and wishes about whether or not to
Interprofessional collaboration involves each
take their medicines, and when and how to take
partner being aware of and valuing the contributions
them, must be respected and considered by health
and perspectives of other professionals, while
professionals if they are to achieve concordance.14
sharing common patient-centred goals or specific
Concordance can be achieved through shared outcomes that they pursue as a team.17 In this case,
decision making. Shared decision making is when the goal is a better treatment outcome for patients
decisions are made by health professionals and through establishing treatment plans and supporting
patients together, using the available evidence patient adherence to them.
and considering and respecting the patients
Module
Present and explain the different categories of against the perceived risks18,19 (e.g. the improved
patient non-adherence to medicines, giving quality of life versus side effects20).
cardiovascular medicine-related examples.
The following sub-categories can be used to
Draw on earlier discussion and feedback
classify patients non-adherence to medicines:
No symptoms/no severe symptoms For example, some side effects can negatively
For example, hypertension, dyslipidaemia. affect adherence. See Table 2 on page 103 for
more information.
Rate of progression and severity of the condition
Reduced access to medicines and/or
For example, heart failure is a progressive condition
medical support
with the potential for gradual aggravation.
For example:
The treatment rural and remote areas with minimal
medical facilities
There are several established factors related to the
the high cost of medicines
patients treatment regimen that may negatively
the inability of older patients to actually get to
impact his/her adherence to medicines. See Table
the health professional.
1 on page 87 for more information.
Complex prescribed regimen The healthcare system
For example:
patients, such as people with heart failure or Facilitator notes
hypertension, who are taking multiple medicines
medicines that need to be administered three Task
or more times per day, for example, captopril Present and discuss the factors related to the
for patients with heart failure, and patients on healthcare system that may impact on patient
multiple medicines after a stroke. adherence to cardiovascular medicines.
Long duration of treatment Activity
For example, the treatment of hypertension, Divide participants into small groups. Ask
dyslipidaemia, heart failure, coronary heart them to discuss the factors related to the
disease and the use of anti-thrombotics in atrial healthcare system that may impact on patient
fibrillation require long-term or even lifelong adherence to cardiovascular medicines which
use of medicines. they can address in their practices. Ask them to
Previous treatment failure outline the factors that are outside their scope.
For example, previous anti-hypertensive medicines
Note: at this stage we are not interested in
did not lower the patients blood pressure.
identifying ways to address the factors we
Frequent changes in treatment just need to focus on the factors themselves.
For example:
frequent changes in medicines, such as
changes to antihypertensive medicines to find
the optimum type of medicine for the patient
frequent changes in doses, for example,
changes in doses of angiotensin converting
enzyme (ACE) inhibitors to get the optimum
effect of the medicines without too many
side effects, or changes in warfarin dose to
maintain appropriate international normalised
ratio (INR).
10 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
The healthcare system can also affect patient Health professionals limited condition-relevant
adherence to medicines by influencing access knowledge and training
to care. The following factors may influence Health professionals need good condition-
patient adherence. related knowledge and training to create the best
Health professionals lack of time possible treatment plan and deliver interventions
to improve patients adherence to medicines.
Consultation times may be too short to
adequately address patient medicine- Limited community support
Module
taking behavior. Patients may not always have access to relevant
Health professionals may be overworked and and appropriate support organisations.
stressed, and have increasing demands placed
on them, leaving less time available for patients.
The socioeconomic context
12 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Loss of faith in medicines knowledge and understanding, for example
For example, a patient is prescribed about the rationale for treatment
spironolactone because the use of diuretics, beliefs, for example about the effectiveness
ACE inhibitors and beta-blockers doesnt improve of treatment.
his/her heart failure adequately. The patient may
Two factors that considerably influence adherence
think that the spironolactone is also not going to
to medicines are the patients knowledge and
work, so doesnt take spironolactone and/or stops
beliefs, which are discussed in more detail below.
Module
taking another medicine, or medicines.
Poor sight Patient knowledge and understanding
For example, patients with poor sight (e.g.
older people) cant read the medicines label or There may be gaps in the patients knowledge
that influence his/her adherence to medicines.
cholesterol levels for years before he had a This is the patients belief in his/her ability to
stroke. The patient becomes adherent because accomplish something, in this case, adherence.
it might happen to him. For example:
Perceived severity patients with a low level of self-efficacy
1: Adherence to cardiovascular medicines the principles
This is the patients belief of how serious or generally feel more helpless and dont believe
severe the condition is if it is left untreated. they can adhere to their medicines
Perceived severity is often based on the patients with a high level of self-efficacy are
information health professionals give patients more likely to engage in treatment, because
and the patients existing knowledge. It may they perceive themselves as being able to
also be based on the patients perceptions of the adhere to medicines and create change in
problems caused by the condition or the effects relation to their condition.
it would have on his or her everyday life.
For example: High levels of self-efficacy can also cause
intentional non-adherence, because some patients
a patient who is not adherent to his
may decide against their health professionals
antihypertensive medicines because he
recommendations as they feel in control of
doesnt feel sick and believes that nothing
making a different decision about their treatment.
will happen to him if he doesnt regularly
For example, a patient who needs to reduce
take his medicines
his/her blood pressure may opt not to take the
a patient who always takes her maintenance
medicine prescribed, but make lifestyle changes
dose of aspirin, because she remembers
instead.26 While positive lifestyle changes are
the myocardial infarction she had several
beneficial, it is important to explain to patients
months ago.
that lifestyle changes alone may not be enough to
Perceived benefit help them achieve optimum health outcomes.
This is the patients belief of the value of
taking medicines to decrease the risk of In addition to these perceptions and beliefs,
developing a (more severe) condition, or patients may also have beliefs about other
the condition worsening. issues that can affect adherence. These include
perceptions about their medicines, the health
For example:
professional/healthcare system and themselves,
the non-adherent patient who doesnt
as outlined below.
see the benefits of taking ramipril to treat
her hypertension Medicines
the patient who believes that a prolonged life Patients perceptions of their treatment and how
doesnt compensate for a reduced quality of it affects their condition can influence whether
life or the disruption to lifestyle that would or not they decide to adhere to it.18 Many
result from taking medicines people have reservations, dislikes or anxieties
the patient with arrhythmias who takes about medicines.24 They often ask the following
diltiazem as prescribed because he feels questions when prescribed a new medicine:
significantly better when he does. how effective is the medicine?
Perceived barriers how likely am I to become addicted?
This is the patients perception of the obstacles should I try a more natural and safer alternative?
to using the medicines, including side effects how likely am I to get side effects?
and costs. can I become immune to the medicine?
For example: can the medicine harm me?
the patient who heard that the medicine
(e.g. warfarin) had many severe side effects,
so is afraid to take it.
14 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
am I able to follow this complex The patients self perception
treatment regimen? Patients perceptions and beliefs about themselves
can I actually take the medicine? are complex and varied. They are also fundamental
will the medicine make a difference to in understanding the patients relationship to
my condition? taking medicines. Three concepts help to explain
patients perceptions of themselves.
1. Health locus of control
Module
Case study
Health locus of control refers to patients
Claire, 89-years-old, has heart failure and beliefs about whether their health is controlled
recently had a severe stroke. In hospital, by their behaviour or external factors.27
her medicine regimen was changed to try to Patients with an internal locus of control
Case study
Sams doctor prescribed him a beta-blocker
and the medicine makes him feel tired.
Because of this, Sam can no longer participate
in local football games or care for a loved one.
Sam has started experimenting with doses so
he can fit in daily chores and enjoy playing
football again.
Review the objectives and learning outcomes non-adherence, it is important to recognise them
of this module. Ask participants to summarise and monitor patients accordingly.
what they have learnt.
To effectively lower a patients absolute CVD risk,
Introduce the next module. all health professionals should be able to:
1: Adherence to cardiovascular medicines the principles
16 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
References
1. Osterberg L, Blaschke T. Drug therapy; 13. Nunes V, Neilson J, OFlynn N, et al. Clinical
adherence to medication. New Engl J of Med guidelines and evidence review for medicines
2005; 353(5):487497. adherence: involving patients in decisions
about prescribed medicines and supporting
Module
2. Benner JS, Glynn RJ, Mogun H, et al. Long-
adherence. London: National Collaborating
term persistence in use of statin therapy in
Centre for Primary Care and Royal College of
elderly patients. JAMA 2002; 288(4):455461.
General Practitioners, 2009.
3. Sokol M, McGuigan KA, Verbrugge RR,
14. Marinker M, Blenkinsopp A, Bond C. From
18 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Module 2: Identifying
patients non-adherence
Learning outcomes
By the end of this module, you will be able to:
demonstrate an increased understanding of indicators that can help to identify patients who are
potentially non-adherent to their medicines
demonstrate an increased understanding of the tools used to identify patients who are non-
adherent to their medicines
Module
demonstrate the use of the tools in measuring and identifying patients who are non-adherent to
their medicines.
It is very important for health professionals to identify patients who are non-adherent to their medicines.
Most of the time, patients will not tell you if they are not taking their medicines as prescribed.
2: Identifying patients non-adherence
In this module, we will discuss indicators that may suggest a patient is not taking his/her medicines
as prescribed, and tools that may help you identify and measure non-adherence.
Important note
Non-adherence must be identified so you can help patients achieve better (or goal) clinical
outcomes and lower their absolute cardiovascular disease (CVD) risk.
To make sure patients have a chance to achieve the best possible health outcomes, structured
protocols and procedures to identify non-adherent patients (to pharmacological therapy and lifestyle
changes) should be implemented in primary care practice.
20 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
When to suspect non-adherence
to medicines
There are many indicators that can highlight
Facilitator notes the possibility of non-adherence to prescribed
treatment. They are largely related to the reasons
Tasks for non-adherence (see module 1, Reasons for
Present a short introduction to the module, non-adherence on page 9 for more information).
including its content, objectives and learning The indicators may be patient-, condition- or
outcomes. medicine-related.
Differentiate between how a health The presence of one or more indicators does not
professional can: necessarily mean patients are not taking their
Module
use a list of indicators to identify patients medicines, though it should raise suspicions.
who may be non-adherent to their medicines
use tools or measures to actually
Remember
identify patients who are non-adherent
have dementia
have emotional instability/are chronically maladaptive
have poor coping strategies
have multiple comorbidities
2: Identifying patients non-adherence
22 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Tools of the trade
If patient non-adherence to medicines is
Facilitator notes suspected, it is important to confirm it. There
are several tools/measurement methods health
Task professionals can use to help them do this.
Introduce the next activity, which will focus on
the methods and measures health professionals There is no gold standard for measuring patient
can use to identify patient non-adherence to adherence to medicines, and no single tool to
medicines (and its extent). detect all types of non-adherence to medicines.
Module
to medicines (including the pros and cons of not practical for routine use. Therefore, health
these methods), and how often they use them. professionals have to rely on less direct and less
sensitive methods to get this information.
Participants should link the methods they use
with the indicators of patient non-adherence A patients adherence to his/her medicines may
Objective methods
Pharmacy refill Shows the frequency Rates Non-invasive No information
records of prescription refills Economical on patterns of
over a specific period. medicine taking
Doesnt record
actual consumption
Patients must get
their medicines
from the one
pharmacy
Pill counts Count pill numbers Rates Easy to use No information
taken out of Inexpensive on patterns of
Module
actual consumption
Data can be
manipulated
by patients
Time consuming
Medication event A microprocessor Rates Non-invasive Expensive
monitoring system attached to the Accurate Doesnt record
(MEMS) medicine bottle Gives information actual consumption
lid records the on behavioural Not practical in
occurrence and time patterns everyday use
of each opening. Cant be used for
medicines that are
not in bottles
Subjective methods
Brief medication Consists of a Rates Brief and easy Can be biased by
questionnaire (BMQ) five-item regimen Barriers to use patients giving
screen, a two-item Beliefs Economical false information
belief screen and
a two-item recall
screen to measure
patients medicine-
taking behaviour and
possible barriers to
adherence.
Morisky Scale The scale consists Rates Brief and easy Can be biased by
of four yes or no Barriers to use patients giving
questions that Beliefs Economical false information
measure patients
medicine-taking
behaviour.
24 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Method How it works Outcome measures Pros Cons
Module
Can be biased by
of illness. patients giving
false information
Beliefs about Consists of two five- Rates Easy to use Can be biased by
medication item scales that assess Barriers Can get detailed patients giving
in their practice for assessing patient consistent access to all pharmacy data, significant
adherence to medicines. Participants should back-end programming for calculations and a
also discuss which of these three methods is closed pharmacy system. They are also unstable
preferred, and why. over shorter intervals. A further limitation is that
2: Identifying patients non-adherence
50
Reproduced with permission of the Pharmacy Guild of Australia.
26 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
The score prompts pharmacists to initiate a Furthermore, pill counts dont give any information
conversation with the patient about their adherence. about the patients pattern of medicine taking, such
If the conversation validates the score, and poor as missing doses or timing variations.
adherence is confirmed, this is a call to action to
the pharmacist to explore strategies for addressing MEMS
adherence (see Figure 1 on page 26). For more
The MEMS is a medicine container with a
information, visit www.medsindex.com.au.
microprocessor that records the date and time of
Pill counts opening, creating a sensitive and accurate record
of adherence to medicines. This tool cant measure
Pill counts are usually done in a patients home the consumption of medicines, only indicating it
(e.g. through a Home Medicines Review), but through the opening of the container.
health professionals may ask patients to bring
The MEMS system itself is not neutral. It can act as
their medicines to consultations so a pill count
a behavioural intervention, enhancing adherence
can be done then.
Module
in some individuals.3 More importantly, the high
Pills are counted at the end of a designated time costs of the container, and the fact that the MEMS
to calculate the patients rate of adherence to cap is for medicines that go into a bottle (and
the medicines. Pill counts dont always give an therefore, not useful for medicines that are in
accurate account of a patients medicine taking, blister packs), make it impractical for routine use.
Patient questionnaires
Module
28 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Indicators of non-adherence to medicines In the BMQ example below, although the
include patients: patient could name all prescribed medicines
failing to mention target medicines (without and had a relatively good understanding of
prompting by a health professional) them, he/she would be considered non-adherent
stating that they cant remember if they took their because he/she missed one dose of each
medicines, or that they forgot to take them medicine prescribed for that week.
not being able to answer questions about their
medicine taking
reporting interruption in, or discontinuation of, use
reporting missed doses.
Module
b) Medicine strength Dont know 50 mg 300 mg
c) How many days did you take it? 6 6 6
d) How many times a day did you take it? 1 1 1
Comment: I dont know which of these medicines causes the side effects.
Below is a list of problems that people sometimes have with their medicines.
Please check how hard it is for you to do each of the following.
3. When you feel better, do you sometimes Questions are based around five aspects of non-
stop taking your medicine? adherent behaviour, and patients place themselves
4. Sometimes, if you feel worse when you on a scale from one to five (one being always,
take your medicine, do you stop taking and five being never). The total points are then
your medicine? calculated to show an indication of the patients
2: Identifying patients non-adherence
30 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Patient beliefs as an indicator
of adherence to medicines
Patients adherence to their medicines is
Facilitator notes influenced by their beliefs and attitudes about their
condition.9,10 Moreover, patient beliefs about their
Task medicines predict their adherence more strongly
Summarise the key points from the module so than socio-demographic or clinical factors.10
far, focusing on the indicators for identifying
potential patient non-adherence to medicines, The Health Belief Model suggests that five key
and the tools that can be used to measure elements determine a patients adherence to
adherence to medicines. medicines. (For more information about the Health
Module
Belief Model, see module 1, pages 1314.)9,10
Introduce the next section on patient beliefs by
reviewing material from module 1 on patient Threat of the illness
beliefs as an important factor in influencing For example, the patients perception of the
adherence to medicines. severity and susceptibility of illness.
my medicines.
condition will last, including recurrence
2. My life would be impossible without
4. consequences: the expected effects and
my medicines.
outcome of the condition
3. Without my medicines, I would become
5. cure or control: the extent to which the
very ill.
2: Identifying patients non-adherence
32 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
A conversation to identify
non-adherence
Facilitator notes
Important tips to remember when
talking with patients about adherence
Task
Introduce the use of conversation within Do Dont
consultations with patients as a means of be open be leading
eliciting information about patient adherence be neutral be judgemental,
to medicines. threatening,
word sentences
Activity and information embarrassing or
Module
Divide participants into small groups. Ask carefully (e.g. reduce emotional
them to identify the non-verbal and verbal memory errors and ask about too many
skills needed to talk with their patients to get misunderstandings) medicines at once
information about adherence to medicines in avoid ambiguous be too broad or
To assess both
It must be hard trying to remember to take the tablets every time. Do you ever forget?
How do you feel about that?
Module
People often have difficulty taking their pills, and I am interested in finding out any problems that
occur so that I can understand them better. Do you ever miss taking your medicine? How often?
When you feel better, do you sometimes stop taking your medicine?
2: Identifying patients non-adherence
34 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Conclusion and key messages
Most health professionals overestimate their
Facilitator notes patients adherence to medicines. They often do not
recognise non-adherence to medicines, which may
Tasks result in suboptimal treatment and health outcomes.
Summarise this module.
There are several characteristics related to
Ask participants to develop their own practices patients, their condition and their medicines that
and/or personal protocols for identifying non- should raise your suspicion about adherence. For
adherence issues. The protocol can include, example, when patients are not responding to
but should not be limited to the following: treatment, have missed refilling a prescription or
set up a register and/or collate a list of patients when their condition is chronic.
on cardiovascular medicines in your practice
When a patients non-adherence to medicines
Module
use an existing questionnaire, or develop
is suspected, it is essential to examine it. There
a brief survey on cardiovascular medicines
are several measurement tools that can be used
based on the tools reviewed in this module,
to do this. However, there is no gold standard
for patients to complete while they are
for measuring adherence to medicines, and no
waiting to see you
36 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Module 3: Creating
concordance and making
shared treatment decisions
increase your understanding of the concept of sharing treatment decisions with patients
(creating concordance)
increase your ability to involve patients in decisions about their treatments
increase your ability to implement strategies to achieve concordance in consultations with patients
3: Creating concordance and making shared treatment decisions
improve your listening skills and explore ways to elicit information from your patients
give you techniques to appropriately present information to patients
increase your understanding of strategies to establish treatment plans, underpinned by the stages
of change model, motivational interviewing and shared decision making.
Learning outcomes
By the end of this module, you will be able to demonstrate:
an increased understanding of concordance and the concept of shared decision making
how to implement strategies to achieve concordance in your consultations with patients
active listening skills and the ability to elicit information from patients
how to provide information to patients in a way that they can understand and act on
how to establish treatment plans involving the patient, underpinned by the stages of change
model, motivational interviewing and shared decision making.
38 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Introduction
Module 1 presented the issue of non-adherence in healthcare. In the past,
Module
patients were seen as the source of the adherence problem. Therefore,
interventions were primarily designed to address patient-centred issues.
More recently, it has been acknowledged that being adherent is a complex
Patient beliefs significantly influence patient Using a stages of change approach can help you
behaviour. Therefore, it is important that patients to achieve an effective treatment plan.
beliefs, thoughts and emotions about their
In this module, we will explore the concepts of
condition, treatments and ability to take medicines
concordance and shared decision making, and how
are respected, considered and explored by health
you can use them in your consultations with patients.
professionals. In other words, health professionals
should aim to reach agreement with their patients
during consultations, as a first step in helping
patients achieve adherence to their medicines.
Concordance
When trying to improve patient adherence,
Facilitator notes remember that the views of both patients and
health professionals are of equal significance.
Tasks As adherence to medicines is influenced by the
Present a short introduction to the module, patients beliefs and his/her ability to take the
including its content, objectives and learning medicines, it is important to consider these things
outcomes. during consultations. When this is not done, it is
Give an overview of concordance and its difficult to reach concordance.
importance in healthcare. Non-concordance denotes a failure of the
patient and prescriber (or pharmacist) to come
to an understanding, and not a failure of the
patient to understand.3
The terms compliance and adherence have been
inaccurately used as synonyms for concordance.
While reading this module, keep in mind that Concordance encompasses all
compliance and adherence refer to the notion relationships between patients, doctors,
of patients following the advice of their health nurses and pharmacists.
professionals. They are a measure of patients
medicine-taking behaviour. Concordance is
the cooperation between the patient and health
professional, and is a measure of their interaction.
Addressing patient needs is the primary focus of a
concordant relationship.
40 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
When asked, patients are often willing to share their It does not necessarily take more time in
views on their condition and medicines, even when the end7 you save time spent undoing
they differ from the biomedical view. Discussions misunderstandings.
between health professionals and patients can lead Many health professionals dont feel that they
Module
to a greater congruence between them. This may have the time to create partnerships with their
lead to increased patient satisfaction and positively patients. However, involving the patient in
influence the likelihood of adherence.6 treatment decisions doesnt necessarily take
Before building a partnership, try to keep the more time.
Introducing discussions with a patient at an
Communication
The importance of good communication skills was Think about time and space: when and where
established centuries ago by Plato, who described Before you even start communicating with
two types of physicians: patients, consider if the timing is suitable.
the free doctor who enters into discourse with Patients may not be ready to communicate or may
his patients and friends not be able to, often due to external constraints.
the slave doctor who does not let the patient It is imperative that you find a private
talk about his individual complaints, but instead environment in which to speak with patients.
gives orders.8 If you cant spend the necessary time to
Which sort of health professional are you? Think effectively communicate with a patient on a
about how you appear when you are tired, stressed particular occasion, consider highlighting the
and/or short of time. most important points, suggesting the patient
gain access to information through other
Communication between health professionals and avenues (e.g. another health professional) and/or
patients can be problematic. We will explore some scheduling another time for a longer discussion.
strategies that can help health professionals achieve
Use the skills of the whole practice team and
good communication with their patients.
of your colleagues from other disciplines.
42 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Patient education
Adequately educating patients is a vital aspect assessing the patients ability to learn
Module
of good treatment, especially when promoting determining the best way to instruct the patient
adherence to medicines and reaching concordance determining the best time to instruct the patient
about treatment. However, often when patients are determining if learning has occurred
diagnosed with a new condition or when they are after instruction
advice should be easy to understand, unbiased and patients know the below.
include technical facts. It should also be balanced,
The expected benefits of a medicine, and how
including both positive and negative information.
and in what time frame it will improve their
When interpreting clinical data and lab results,
health and quality of life.
3: Creating concordance and making shared treatment decisions
44 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Establishing a treatment plan
After you have given the patient all the relevant
Module
Facilitator notes information, start developing his/her treatment
plan. It should be a personalised treatment plan
Activity made through shared decision making, based
Divide participants into small groups. Ask them on the patients beliefs and readiness to change
Patient beliefs
When making a treatment plan, it is very important
to consider the patients beliefs, as they will Remember
provide you with information that will help you to The stronger the patients belief that he/she is
know if the patient will adhere to a treatment plan. capable of achieving the behaviour, the more
The Health Belief Model illustrates the subjective likely it is that he/she will engage in self-care.
interpretation of a health condition and the An increase in self-efficacy equates to an
importance of this in managing disease and increase in self-management.
treatment. This model, and the key factors regarding
patient beliefs that should be considered when
speaking with a patient, are explained in module 1.
health behaviour: starting with the costs. Outline what is good and
1. pre-contemplation bad about not taking action, and then what is good
2. contemplation and bad about taking action. For example:
3. preparation taking the simvastatin will cost you up to
4. action $37.53 a month*
5. maintenance. simvastatin significantly decreases the risk of a
cardiac event
People dont necessarily go through each stage in
turn. They may also stay within one stage, never taking simvastatin can occasionally cause some
moving to the next. side effects, such as muscle pain.
Below are some ways that you might recognise Discuss treatment options with patients.
where your patients are within the model and For example:
some suggestions for how to support them. we can first just try to lower your cholesterol
with diet and more exercise
Pre-contemplation if this does not work, we can try simvastatin
a cholesterol-lowering medicine.
During pre-contemplation, it is often difficult for
health professionals to talk with patients about
taking medicines, because the patient is not At this stage, dont discuss how patients
considering making changes to his/her behaviour. could change.
During this stage, it is helpful to bring patients Commend any positive action patients take.
attention to their behaviour and its consequences.
Give them helpful, general information to raise
their awareness, such as At the moment, you are Preparation
not taking your simvastatin. This may increase your
risk of a heart attack in the future. Preparation is where patients have intention and
motivation to follow treatment.
Try to get information about their locus of control
or who they believe (perhaps subconsciously) is in Give patients practical advice.
control of their treatment as well as their level of
Set goals with patients. Include dates, clear aims
self-efficacy (see module 1). Find out how much
and a plan of action. For example:
they believe they can change their situation and
the patients cholesterol should be lowered
take part in their treatment.
by X mmol/L within Y weeks (dependent on
the patient) by eating healthier foods, being
Dont argue or try to convince them to change. more physically active and taking medicines
as prescribed
the patient should take the simvastatin once a
day at night link taking the medicine to a daily
activity, such as brushing teeth.
46 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Self-efficacy is paramount. Make sure patients feel Maintenance
in control of their treatment decisions, and where
possible, their treatment. During the maintenance stage, patients adhere
to their treatment plan automatically, without
Schedule frequent meetings with patients.
Module
any conscious effort. Treatment management has
Discuss with patients how you can help them become second nature to them, but they may
adhere to their treatment plan. For example: relapse into previous non-adherent behaviour.
would you prefer it if we give you the Continue to encourage your patients to adhere to
simvastatin in a dose administration aid to help
Action
During this stage, patients are actively and
consciously adhering to their treatment plans.
Encourage and support your patient, for example:
you are doing a good job with taking your
medicines keep it up!
Discuss with patients their progress and successes,
even if they do not see these things. For example:
by taking your medicines, you have lowered
your blood cholesterol levels and significantly
decreased the chance of a cardiac event.
Highlight your patients responsibility in their
healthcare. For example:
It is important to keep taking your medicines to
keep your cholesterol at this level.
are established, health professionals can develop plan is partly dependent on how health
a treatment plan through shared decision making professionals establish it. While shared decision
with the patient. making is a valuable process, there is no specific
guide to achieve it. Shared decision making is
Positive aspects of the shared decision making
3: Creating concordance and making shared treatment decisions
48 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Goal setting
Begin establishing treatment goals with a patient In establishing goals, patients priorities should
Module
by first setting out the treatment priorities as you lead the decision.15 Stick to realistic goals, and
see them, then making recommendations about remember to make goals SMART (specific,
changes that will enhance the patients health.15 measurable, achievable, realistic and timely).
For example, to achieve reductions in a patients For example:
Diet Exercise
yoga?
Work
Quit flexible working
smoking hours
Work with your patients to fill in the circles by asking what they think might help them better
manage their condition, and write this information in the blank circles.
Then choose a priority area. You might ask: Which of these do you feel most ready to change?
Activity
Module
50 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
References
1. Britten N, Stevenson FA, Barry CA, et al. 9. Agard A, Hermeren G, Herlitz J. When is a
Module
Misunderstandings in prescribing decisions in patient with heart failure adequately informed?
general practice: qualitative study. BMJ 2000; A study of patients knowledge of and attitudes
320:484488. toward medical information. Heart Lung 2004;
33(4):219226.
2. World Health Organization. Adherence to
52 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Module 4: Aiding patient
self-management in
cardiovascular care
Learning outcomes
By the end of this module, you will be able to:
demonstrate an increased understanding of the principles of patient self-management
4: Aiding patient self-management in cardiovascular care
describe and demonstrate the skills that are needed to effectively support patient self-management,
specifically self-management of cardiovascular disease (CVD)
describe the role health professionals play in helping patients to better self-manage their condition.
54 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
The principles of self-management
Facilitator notes
How to help patients self-manage
their condition
Tasks
There are seven key components to helping
Module
Present a short introduction to the module,
patients self-manage their condition.4
including its content, objectives and learning
outcomes. 1. Give patients information about their disease
state, medicines and relevant support groups.
Activity
2. Teach patients specific skills in managing
professionals need to help patients better can confirm patients understanding and identify
self-manage their condition. areas for further education. Some questions that
Feedback health professionals might ask patients to begin
Ask groups to present the skills they with are outlined below.
have identified.
For patients with a new diagnosis
Task
Summarise the skills identified by the What do you know about (the condition)?
participants and give extra information What would you like to know about
about these and any other relevant skills not (the condition)?
described by the participants. What do you know about the medicines
used for (the condition)?
There are some essential skills health For patients with an established diagnosis
professionals need to help them give patients What would you like to make sure we
the best possible support.6 discuss today?
Please tell me about the things that have been
Communication skills tough for you, in terms of your disease and
Good communication between health medicine taking?
professionals and patients is fundamental to What kinds of problems, if any, are you having
patients successfully self-managing their condition. with your medicines?
The key skills health professionals need for
After receiving answers to the first round of
effective communication with patients are:
questions, health professionals can then give
listening to patients (in terms of information and patients relevant information, ask if extra
feelings/experiences) information is needed and check that the
asking questions related to patients experiences information given has been understood.
giving patients relevant information.
To make sure patients understand the information
These skills can be improved through education given to them, health professionals could ask
and practice.6 questions such as:
It is common for patients to receive too much or please explain to me in your own words how
too little information about their condition. This you will take your medicine?
can cause misunderstandings and result in patients what side effects will you look for, and what will
having a limited knowledge and understanding of you do if they occur?
their treatment.7
56 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Remember to also use the communication/ Psychosocial skills
interviewing skills discussed in modules 1 and 3.
To support patients, health professionals need
The ask, tell, ask approach will help you to give
to understand the impact of CVD on the patients
patients information in a way that is directed by the
life. Consider:
individual patient, thereby overcoming the problem
viewing the situation from the patients
of giving too much or too little information.
perspective how would you feel?
taking a public health perspective
Module
Listen more than you talk! involving patients in their own care
giving comprehensive or whole-of-patient care
acknowledging the stress and demands that CVD
Knowledge of available places on a person, their family and friends
58 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Health professionals can do the following to help Agree
patients self-manage their condition.
The importance of reaching concordance was
Suggest to patients ways they can manage their
discussed in module 3. With regard to self-
condition by reducing or removing modifiable
management, it is important to collaborate to
risk factors. For example:
develop a patient-specific, achievable action plan
quitting smoking that describes:
following a healthy or personalised diet what: the specific task the patient is going to
Module
being more physically active. undertake before the next meeting
Explain to patients how to monitor their own care. when: a specific time to perform the task
For example: how often: how often the patient should do
weighing themselves regularly the task
How convinced are you that this is the right work for you:
0 1 2 3 4 5 6 7 8 9 10
Totally Unsure Somewhat Very Extremely
4: Aiding patient self-management in cardiovascular care
1.
2.
3.
1.
2.
3.
The ways I can overcome those things that might get in the way:
60 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Assist When patients are sticking to their action plans
and reaching the agreed goals, it is important to
Health professionals are responsible for helping encourage them. For example, you could say:
patients when they have a problem with their Youve done a good job
treatment and arent able to help themselves. Ways Now that you are taking your medicines
health professionals can help patients include: regularly, you have considerably reduced your
identifying the barriers to self-management that risk of developing heart disease in the future.
patients perceive or experience
Module
working with the patient to overcome these barriers Arrange
reviewing treatment action plans with patients
Maintain your interest in your patients self-
and adjusting them if patient views, aims or
management action plan and provide ongoing
capacity have changed
62 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Module 5: Interventions
to improve your patients
adherence
Learning outcomes
By the end of this module, you will be able to:
identify evidence-based interventions that have been shown to improve adherence to
cardiovascular medicines and clinical outcomes
5: Interventions to improve your patients adherence
describe practical interventions that can be integrated into daily practice to improve patient
adherence to cardiovascular medicines.
64 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Interventions that
improve adherence
If you have concluded that a patient is non-
Facilitator notes adherent, there are several strategies you can
implement to remedy the situation. The literature
Module
Task on adherence to medicines in cardiovascular
Present a short introduction to this module, care (e.g. hypertension, dyslipidaemia, chronic
including its content, objectives and learning heart failure and coronary heart disease)
outcomes. highlights several interventions that have
significantly improved adherence to medicines.
66
Interventions that improve adherence
Intervention Disease Effect on adherence Effect on clinical outcomes
(compared with control/comparison group) (compared with control/comparison group)
Information giving
Patient-centred verbal instructions and Heart failure After the intervention period, 10.9% more doses 19.4% fewer exacerbations of heart failure.2
written information about medicines taken; 5.9% more doses taken on time; 4.2%
more refills. However, this effect faded over time.2
Behavioural interventions
Motivational counselling Heart failure A day without the patient using medicines was No significant changes in percentage of patients
three times less likely to occur.3 re-admitted or death.3
Dyslipidaemia Patients took 24% more of their lovastatin and After two years, total cholesterol was 6.8%
23% more of their colestipol after two years.1 lower, LDL 9.4% lower and triglycerides 6.3%
lower, with no significant change in HDL level.1
Hypertension Percentage of adherent patients was 6% higher.4 DBP was 4.4 mmHg lower. No significant
change in SBP.4
There were 12.8% more doses taken.5 No significant changes in SBP and DBP.5
Calendar blister packages Hypertension Percentage of patients that had their No significant changes in SBP and DBP.6
prescription refilled on time was 14.3% higher.
The MPR* was 0.06 points higher.6
The transtheoretical model Hypertension Percentage of patients in the action or maintenance No clinical outcomes measured.7
(TTM)-based expert system stage of change was 9.9% higher and the
questionnaire score indicated better adherence.7
Telephone calls and mailings to encourage Hypertension Percentage of adherent patients was 30% higher In the telephone group, the SBP was 9.5 mmHg
patients and remind them of their next visit in the group that received telephone calls, and lower and DBP 7 mmHg lower. No significant
22.1% higher in the group that received mailings.8 changes in SBP and DBP in the mail group.8
Abbreviations: BMI: body mass index; DBP: diastolic blood pressure; HDL: high-density lipoprotein;
LDL: low-density lipoprotein; MPR: medicines possession ration; SBP: systolic blood pressure.
* The MPR calculates the percentage of time a patient has access to medicines. The number of doses that a
patient obtained over a period of time is divided by the number of doses that should have been obtained.
68
Interventions with contradictory results
Intervention Disease Effect on adherence Effect on clinical outcomes
(compared with control/comparison group) (compared with control/comparison group)
Behavioural interventions
Home blood pressure measuring Hypertension Percentage of adherent patients was 18% higher.15 DBP was 3.1 mmHg lower. No significant
change in SBP.15
There were 7% fewer doses taken.16 DBP was 6.7 mmHg lower; mean arterial
pressure was 7.8 mmHg lower. No significant
change in SBP.16
Regimen simplification Hypertension and Percentage of patients with medicines supplied No clinical outcomes measured.17
dyslipidaemia for 80% of the days was at least 20.3% higher
and the percentage of persistent patients was at
least 10% higher (intervention group compared
with four comparison groups).17
Dyslipidaemia and ischaemic There were 11% more doses taken.18 Total cholesterol was 14 mg/dL lower, LDL was
heart disease 13 mg/dL lower and HDL was 4 mg/dL lower.
No significant change in triglycerides.18
Heart failure Percentage of doses taken did not improve as a No significant changes in SBP, DBP,
result of the intervention.19 hospitalisations and BNP levels.19
Abbreviations: BNP: brain natriuretic peptide; DBP: diastolic blood pressure; HDL: high-density lipoprotein;
LDL: low-density lipoprotein; SBP: systolic blood pressure.
Module
Similar booklets about hypertension can be
Divide participants into small groups. Ask found online at www.hypertensionfoundation.org/
them to discuss the types and formats of booklets.cfm.
information they routinely give patients with
cardiovascular disease to make sure they Other interventions are outlined below.
Behavioural interventions
Facilitator notes
Motivational interviewing
Motivational interviewing (also called
Task motivational counselling), has shown positive
Briefly introduce this section and the activity. results in improving patient adherence to
Activity cardiovascular disease treatment. Patients with
Divide participants into small groups. Ask them heart failure, dyslipidaemia and hypertension have
to discuss any behavioural interventions that all benefited from this approach.
they have used to promote patient adherence to However, to integrate motivational interviewing
cardiovascular medicines. into consultations, health professionals need to
Feedback allocate extra time.
Ask groups to give feedback on the behavioural
interventions they think would improve and Motivational interviewing is a directive,
maintain patient adherence to medicines. client-centred counselling style for eliciting
Task behaviour change by helping clients to
In receiving and reviewing the feedback, explore and resolve ambivalence.20
focus on motivational counselling and the
transtheoretical model (TTM)-based expert Motivational interviewing is a complex skill that
system. In particular, look at the advantages takes time and practice to learn. It is based on the
of these interventions, the barriers to their Stages of Change (readiness-to-change) model
use and how these interventions can be outlined in module 3.
implemented in practice. In motivational interviewing, health professionals
work with patients to help patients move from
unhealthy behaviour to healthy behaviour,
through the stages of change. Motivational
interviewing is more focused and goal directed
than non-directive counselling.
70 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
While implementing motivational interviewing The Heart Foundation has developed the
you should:21 Motivational interviewing professional
development kit to help health professionals
Express empathy
adopt this technique. The kit contains two DVDs
E mpathy will help you to understand the
and a health professional reflection tool. Visit
patients perspective.
www.heartfoundation.org.au or call the Heart
It will help the patient to feel comfortable and Foundations Health Information Service on 1300
open up to you. 36 27 87 for more information and to order the kit.
Empathy also helps you to identify which
points the patient needs support with. The transtheoretical model
Module
Support self-efficacy (TTM)-based expert system
Self-efficacy is important in helping patients
maintain their motivation to change. The TTM is also based on the Stages of Change
Value the patients perspective model. It incorporates process-related variables to
not taking the medicines and the impact that come in these packages. For medicines that
would have on his/her health. dont, it may help to give patients their medicines
Process of change in a Webster-pak. Webster-pak aids adherence
Feedback indicating whether or not a patient to medicines, especially among patients taking
5: Interventions to improve your patients adherence
72 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
These interventions can be conducted at regular Before patients start measuring their blood pressure
intervals, forward planned and undertaken at at home, it is important to instruct them on how to
quieter times within a practice. A specific staff do it. Some important points to tell patients are to:
member can be allocated to contact and send measure their blood pressure every morning
reminders to patients. measure their blood pressure before consuming
A system for recording details of telephone calls any food, coffee or medicines
in which a need for more advice is identified measure their blood pressure after a five-minute
should be implemented. rest in a seated position
measure their blood pressure for a second time
Module
Home blood pressure monitoring after two to five minutes
Home blood pressure monitoring lets patients document the readings each time.
participate in the management of their Blood pressure monitoring machines can be
hypertension. Self-measurement every morning bought from pharmacies. The more features a
74 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Social support plus education
Social support: findings from research
This intervention combines educational and
social components. Research has shown that patient adherence
to medicines improves as a result of social
support from volunteer lay health mentors
Education
and health professionals.
Educate patients about their condition,
Volunteer lay health mentors12
medicines and lifestyle.
The intervention involved participation in a
For practical options, see Informational
Module
mentor-led group. Issues relating to coronary
interventions on page 69.
heart disease, its management and self-help
were discussed and included:
Social support
smoking
It is important to emphasise interactions diet and exercise
possible causes of their condition, such as being to someone who can help him/her take
overweight, high salt intake, lack of physical his/her medicines.
activity and stress
consequences of their condition (e.g. risk of
stroke, coronary heart disease and heart failure)
necessity for long-term medical treatment.
76 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
References
1. Faulkner MA, Wadibia EC, Lucas BD, et al. 10. Sclar DA, Chin A, Skaer TL, et al. Effect of
Impact of pharmacy counseling on compliance health education in promoting prescription
and effectiveness of combination lipid-lowering refill compliance among patients with
therapy in patients undergoing coronary artery hypertension. Clin Ther 1991; 13(4):489495.
revascularization: a randomized, controlled
11. Lee JK, Grace KA, Taylor AJ. Effect of a
trial. Pharmacotherapy 2000; 20(4):410416.
Module
pharmacy care program on medication
2. Murray MD, Young J, Hoke S, et al. Pharmacist adherence and persistence, blood pressure,
intervention to improve medication adherence and low-density lipoprotein cholesterol. JAMA
in heart failure: a randomized trial. Ann Intern 2006; 296(21):25632571.
Med 2007; 146(10):714725.
78 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Module 6: Specific roles
of health professionals
Learning outcomes
By the end of this module, you will be able to:
describe the importance of adherence to improving outcomes in cardiovascular care
individualise patient communications that focus on adherence
describe the specific roles of health professionals in improving patients adherence
using a multidisciplinary approach, identify the systems change needed to improve the
identification and management of sub-optimal adherence in your practice.
Module
Introduction
6: Specific roles of health professionals
80 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
What you can do to help patients
adhere to their medicines
Ask your patients about any psychological
Facilitator notes and/or physical symptoms.
Ask your patients about any changes in their
Task circumstances, side effects or medicine-taking
Present a short introduction to this module, behaviour since the last visit.
including its content, objectives and learning
Ask your patients how they are going with
outcomes.
their treatment plan.
Activity Ask your patients if they have seen any other
Divide participants into small groups. Ask clinicians. Make sure you share medical
Module
them to brainstorm all the ways that each information with other appropriate providers
health professional can help patient adherence and institutions (with the patients consent).
to medicines. Respond to cues that might indicate your
Feedback patients non-adherence to their medicines.
82 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Written instructions must be simple. Give the reinforce important information, provide additional
patient a copy of the instructions on the medicines information and clear up misunderstandings
in a larger printed format (such as A4), and go monitor the effectiveness of medicines
through them with him/her carefully.9 use telephone reminder systems to prompt
During a follow-up consultation: patients to fill repeat prescriptions
assess the patients response to treatment measure patient blood pressure, cholesterol and
reassess his/her adherence and any difficulties in international normalised ratio, to help monitor
taking the medicines the effectiveness of medicines and support
patient adherence to medicine
problem solve difficulties using the
patients preferences conduct a medicine review, if applicable
adjust treatment to achieve an optimal outcome tailor treatment to fit patients lifestyles
facilitate medicine refills and follow-up care. counsel patients, for example, using
motivational interviewing
GPs may initiate a Home Medicines Review educate patients about their condition, the risks
(HMR, MBS Item 900) when non-adherence is
Module
and benefits of treatment, lifestyle information,
suspected. The HMR is initiated by writing a the medicine that has been prescribed, its dose
referral to the patients pharmacy. The referral and potential side effects11,12
should include relevant clinical information (i.e.
give patients information and advice about
diagnosis, recent laboratory results and list of
the use of tools, such as dose management,
Ongoing monitoring
When the disease/condition is
Patients adherence to medicines should be
diagnosed/new medicine prescribed
monitored on an ongoing basis at frequent intervals
The GP/nurse should: by all health professionals involved in their
give patients written and verbal information care. The intervals will depend on the patients
about their condition and relevant medicines circumstances (e.g. changes in therapy, condition
give patients information about relevant and personal circumstances).
support services
suggest patients talk to their pharmacist about Ongoing monitoring should occur at every
their medicine. interaction with the patient and can start by
The pharmacist should give patients: simply asking the patient How have you been?
specific information about their medicines How are you going with your medicines?
the Consumer Medicine Information for
their medicines.
84 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Conclusion and key messages
GPs and pharmacists have the greatest contact
Facilitator notes with patients in general. Therefore, they have
an important role in discovering patients non-
Task adherence to their medicines and helping patients
Review the objectives of the module and to improve it. GPs are responsible for finding a
summarise the key messages. suitable treatment plan and helping the patient
manage it. This should be accomplished through
shared decision making, good communication
In addition to the general tasks a health professional with the patient and other health professionals, and
can undertake to improve patients adherence, such simplifying the dose regimen as much as possible.
as checking patients knowledge and understanding
Pharmacists can also identify non-adherence by
Module
and giving personalised information and support,
checking how often patients refill their prescriptions
each health professional has his/her own role in
through the dispensed medicine history or direct
improving adherence to medicines.
patient questioning. When patients appear to be
Community nurses should do a basic follow up non-adherent, pharmacists are in a good position to
86 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Table 1: Barriers to medicine adherence
and treatment strategies
Condition-related
Barriers: categories Barriers: subcategories Cardiovascular examples Strategies
Long duration Long-term treatment of Begin patient education at time of diagnosis. Use risk communication tools. Education
of therapy hypertension to maintain target should include the rationale for therapy, risk vs benefit discussions, clarification of the
blood pressure (BP). patients expectations and identification of useful treatment outcome markers.
Long-term treatment of dyslipidaemia Share with the patient the decision of whether or not to treat and which option to use.
to maintain target lipid levels. Involve the patient in actively planning his/her treatment.
Use of angiotensin-converting Educate the patient about ways to adhere to his/her medicines regimen, for example,
enzyme inhibitors (ACEI), or how to incorporate medicine taking into a daily routine.
angiotensin II receptor antagonists Educate the patient on how to recognise and manage possible side effects.
(ARA), and beta-blockers in
Give the patient personalised written information about his/her treatment regimen.
systolic heart failure.
Set evidence-based treatment goals (e.g. BP and lipid levels) for the patient to work towards.
Use of beta-blockers, calcium
Provide supportive consultations between health professionals and the patient, using
channel blockers (CCB) or long-
positive reinforcement; referral to key resources (e.g. Heart Foundation website) or support
acting nitrates in stable angina.
groups to help reinforce treatment goals and benefits.
Use of antiplatelet agents, beta-
Regularly monitor treatment (e.g. assess efficacy and side effects).
blockers, ACEIs (or ARAs) or statins
post-myocardial infarction (MI). Monitor patient adherence (may use a validated instrument, such as the Morisky Scale4).
Long duration of Statin therapy, antiplatelet agents or Make sure the patient understands how the benefit of treatment (e.g. prevention of cardiovascular
prophylactic treatment ACEIs (or ARAs) in preventing future disease (CVD), transient ischaemic attack (TIA), stroke) outweighs the inconvenience of the
cardiovascular events in people treatment (e.g. cost, alteration of lifestyle). Use specific risk communication tools.
with coronary heart disease (CHD) Agree on a management plan with the patient.
or at high absolute risk of CVD. Educate the patient on how to use and manage his/her medicines.
Use of beta-blockers post-MI. Educate the patient on how to prevent, recognise and manage possible side effects.
Use of warfarin or antiplatelet
Educate the patient about ways to adhere to his/her medicines regimen, such as
87
88
Table 1: Barriers to medicine adherence and treatment strategies (continued)
Large number of Multiple medicines for Use of beta-blockers, CCBs, and/or Educate the patient on the use of medicines and rationale for using more than one medicine.
medicines one disease state long-acting nitrates in stable angina. Simplify medicine regimens (e.g. reduce the number or frequency of medicines taken per day).
Use of ACEIs, beta-blockers and/or Consider longer-acting and combination medicines. Make sure the patient is fully aware when
diuretics in heart failure. changed to a combination dose form. This option may not be appropriate in older people.
Use of beta-blocker, aspirin, statin, Give the patient clear instructions.
ozetimibe, clopidogrel, long-acting Prepare a MediList for the patient to use as a guide to the therapeutic regimen.
nitrate, nicorandil, fish oil, ACEI (or Use adherence aids (e.g. dose-administration aids, such as pharmacy-dispensed
ARA) in advanced CVD. Webster-paks), reminders at home (e.g. alarms) or associate taking medicines with a routine
event (e.g. take morning medicines after breakfast or after brushing teeth).
Follow up by health professionals (e.g. the patient makes regular appointments with
prescribers, pharmacists and prescribers monitor rates of prescription refills and/or conduct
a Home Medicines Review).
Therapy-related
Barriers: categories Barriers: subcategories Cardiovascular examples Strategies
Large number of Multiple medicines Statin therapy, antiplatelet agents B egin patient education at diagnosis. Offer suitable websites for support.
medicines for one disease state or ACEIs (or ARAs) in preventing R ationalise/simplify treatment regimen (e.g. medicine review services).
Multiple medicines future cardiovascular events in C ontinually monitor and reassess treatment.
for several conditions patients with CHD.
See strategies above in Condition-related factors
Patients concerns Antiplatelet agent, beta-blocker,
about interactions ACEI (or ARA) or statin post-MI as
well as diabetes medicine.
Multiple doses Some ACEIs and beta-blockers C
hoose an alternative from the same class that requires less frequent administration (long
per day require more than one dose per day. half-life alternatives), a sustained release (SR) form or combination formulations/products,
where appropriate.
C
onsider using non-oral formulations, where appropriate and available (e.g. patches), that
may help patients who tend to forget to take oral formulations on a daily basis adhere to
their medicines regimen.
Side effects Side effects that Cough with ACEIs. Regularly assess and manage side effects, including monitoring processes.
make the patient feel Swollen ankles, reflux and Explain to the patient how side effects can be recognised and managed.
uncomfortable constipation with CCBs. Give the patient an alternative medicine from a different drug class.
Side effects that Muscle pain with statins. Discuss with the patient the risks vs benefits of each medicine.
impact on the Fatigue with beta-blockers. Establish that a side effect is due to the medicine in question and not coincidental (e.g.
patients lifestyle Skin discolouration and bruising check BP for suspected orthostatic hypotension, discontinue and restart treatment to see if
Patient incorrectly with anti-thrombotics. symptom returns, question if it is due to the disease of interest or comorbidity).
thinks symptoms are Diuresis at inconvenient times Encourage discussion/feedback on how the patient feels, so that he/she wont discontinue or
side effects from diuretics. choose when not to take the medicine (e.g. not before sport, special occasions).
Sexual dysfunction with
beta-blockers.
Frequent changes Changes in drug class for the Minimise changes in antihypertensive medicines.
in medicines treatment of hypertension. Monitor the patients adherence to make sure that lack of response is not due
to non-adherence.
Remember that low-dose combinations are superior to high-dose monotherapy for BP
control and side effect profile.
Update the patients MediList to reflect changes in medicines (MediList should be updated
by the doctor or pharmacist and dated according to the most recent update).
Patient-related: intentional
Barriers: categories Barriers: subcategories Cardiovascular examples Strategies
Lack of symptoms Patient feels well Patient doesnt believe high E ducate the patient about the necessity and benefits of adherence for the prevention of CVD
BP is serious because there are (focusing on long-term benefits). Refer to relevant resources.
no symptoms. C larify the patients expectations of therapy and identify useful treatment outcome markers
Patient doesnt believe high lipid (e.g. lipid and BP levels, target INRs for warfarin).
levels are serious because there U se risk communication tools.
are no symptoms. U se meaningful numbers/statistics to clarify to the patient the reason for taking the
Patient doesnt believe stroke prescribed medicines.
89
90
Table 1: Barriers to medicine adherence and treatment strategies (continued)
Perceived side effects Patient misinterprets Patient belief that warfarin is ratsak. Explore the patients concerns and correct any misunderstandings, especially when the
media reports Patient belief that aspirin gives medicine is first prescribed.
Patient misinterprets you ulcers, kidney stones etc. Investigate possible side effects.
Consumer Medicine Patient belief that beta-blockers Address perceived barriers to following the treatment. For example, can the patient open the
Information (CMI) block everything (make medicine bottle with a child-proof lid (rheumatoid arthritis in finger joints)? Can he/she read
Patient believes that people slow). the instructions clearly on the label (eye problems)?
he/she will experience C larify to the patient therapeutic management and a monitoring plan to prevent or manage
the side effects the any side effects.
doctor or pharmacist
mentioned
Patient has
experienced side
effects with other
medicines
Patient incorrectly
interprets symptoms
as side effects
Mythology regarding
medicine
Patient insists that drug
is causing side effects
Rejection of diagnosis Patient doesnt believe that he/she Show the patient his/her pathology results. Explain the results and what the related
has dyslipidaemia, because there targets/goals are.
are no symptoms. Explore the patients ideas and concerns about diagnosis and why he/she has rejected it.
Patient doesnt believe that he/she Calculate the patients CVD risk, and show him/her how CVD risk is reduced with a
has hypertension, because there reduction in risk factors.
are no symptoms. Educate the patient about the role of dyslipidaemia in atherosclerosis and CVD.
Patient doesnt believe that he/she Refer to patient stories/journeys through illness.
has had a heart attack or stroke.
Establish the patients lay epidemiology (i.e. what he/she believes is causing the problem),
and address this.
Not understanding Patient feels well Patient belief that dyslipidaemia Educate the patient about the role of his/her risk factors in atherosclerosis and CVD.
the importance of without the medicine has negative health consequences Calculate the patients CVD risk and show him/her how CVD risk is reduced with a
medicines Patient doesnt that are far in the future. reduction in risk factors.
appreciate the Patient doesnt appreciate the Explore the patients understanding of CVD and how his/her medicine works.
consequences of importance of reaching target BP. Reinforce to the patient that treatment is based on lifestyle changes, but medicines bring
not taking his/her Use of statins in all patients with additional benefits. Lifestyle changes can minimise the dose of medicines he/she needs to take.
medicines CHD may be misunderstood.
Patient believes that
the problem can
be fixed simply by
improving his/her diet
and exercising
Interpersonal skills Patients inability to Patient has language problems, is Ask the patient to explain any concerns he/she has about their health or medicines.
communicate his/her a poor communicator, or does not U se good interview and active listening skills to find out what the patients concerns are.
understanding of their want to upset the health professional. C ounsel the patient constructively and non-judgementally.
condition with the
prescriber
Loss of faith in Patients belief Patient has a CVD event Clarify what the patients expectations of treatment are and use a risks vs benefits equation
medicines that there is little (e.g. an MI or a stroke) while (especially refined risks/benefits ratio if the patient has had a primary event).
improvement in taking medicine. Review medicines and adherence to medicines.
his/her condition Continually monitor and reassess treatment.
Explain to the patient that an event while taking medicine does not mean that the medicine
has failed entirely (e.g. it may have delayed or lessened the severity of the event).
Cost Some brands attract a brand S implify the treatment regimen.
premium on the Pharmaceuticals P rescribe generic equivalents when appropriate (remember that changes can confuse
Benefit Scheme (PBS) (e.g. ACEI some patients).
brands). Avoid brands where PBS brand premium applies.
Multiple medicines for CVD Consider fixed-dose combination products once patients have been stabilised with
and/or other conditions. single-ingredient preparations.
91
92
Table 1: Barriers to medicine adherence and treatment strategies (continued)
Burden of therapeutic Use of antiplatelet agent plus Tailor the patients medicines regimen to his/her daily activities.
regimen ACEI or ARA, beta-blocker and M ake sure the patient understands how the benefits of treatment outweigh the inconvenience.
statin post-MI. H elp the patient compare the perceived risks of treatment versus the risk of developing CVD.
Patient may have other co-existing O ffer the patient a dose-administration aid (e.g. Webster-pak).
conditions requiring medicines.
D iscuss with the patient ways of incorporating monitoring activities (e.g. INR monitoring for
warfarin) into daily/weekly/monthly routines, or alternative modes of monitoring (e.g. point-
of-care testing devices).
Consider prescribing fixed dose combination products that reduce pill count (e.g. statin/CCB).
C onsider prescribing agents that have indications for comorbidities (e.g. alpha-blocker for
males with hypertension and lower urinary tract symptoms).
Patient-related: unintentional
Barriers: categories Barriers: subcategories Cardiovascular examples Strategies
Administration Patient cant swallow Large tablets (e.g. potassium P rescribe an alternative formulation (e.g. liquid form, patch) if available.
difficulties tablets/capsules supplement). Avoid child-proof containers or ask the pharmacist to repackage the medicine.
(especially SR Patient doesnt know that diuretics Use an alternative dose-administration aid that is easier for the patient to open.
formulations) should be taken in the morning. Ask carers (professional carer support and/or family/friends) to help the patient take
Patient cant open Patient doesnt understand the his/her medicine.
medicine containers need for a 1012-hour nitrate-free G ive the patient clear verbal instructions about his/her medicines, using a translation service
Patient cant pop period each day. if necessary. This is especially important for people with poor literacy and older people.
the pill out of blister Patient doesnt understand K eep information simple and straightforward.
packaging the dietary precautions needed
G ive the patient written instructions and/or dose tables/schedules.
Patient doesnt with warfarin.
G ive the patient a translated version of written information and dispensed medicine labels
understand or Patient doesnt understand that SR
if necessary.
remember information formulations must not be crushed.
provided verbally U se pictograms where appropriate (e.g. for the administration of SR tablets or awareness of
vitamin K-containing foods).
Patient cant
understand the written
instructions provided
on the label or in CMI
due to language or
literacy barriers
Not knowing how to Patient cant understand Patient doesnt know that diuretics Give the patient clear verbal instructions about his/her medicines, using a translation service
take the medicine or remember the should be taken in the morning. if necessary. This is especially important for people with poor literacy and older people.
because of language or information provided Patient doesnt understand the need Keep information simple and straightforward.
literacy barriers verbally for a 1012-hour nitrate-free period Use written instructions.
Patient cant understand each day. Simplify dose schedules.
the written instructions Patient doesnt understand the dietary Use medicines that need fewer doses per day or once-daily administration.
on the label or in CMI precautions needed with warfarin.
Tailor the patients medicines regimen to his/her daily activities.
due to language or Patient doesnt understand that SR
literacy barriers Give the patient personalised written information about his/her treatment regimen and/or
formulations must not be crushed.
dose tables/schedules.
Some statins need to be given at
Give the patient a translated version of written information and dispensed medicine labels
night, and BP medicines taken in
if necessary.
the morning.
Use pictograms where appropriate (e.g. for the administration of SR tablets or awareness of
Some beta-blockers need to be
vitamin K foods).
taken twice a day.
Speak with the patients primary carer about the patients medicines.
Frequent dose adjustment in
Clarify with the patient the link between treatment outcomes/goals and the medicines
warfarin therapy.
regimen (e.g. INR and warfarin dose).
Recommend dosing aids.
Regimen complexity Older patient Some statins need to be given S implify dose schedules.
Patient has a at night, and BP medicines taken U se medicines that need fewer doses per day or once-daily administration.
busy lifestyle in the morning. Tailor the patients medicines regimen to his/her daily activities (e.g. meals).
Some beta-blockers need to be G ive the patient personalised written information about his/her medicine regimen and/or
taken twice a day. dose tables/schedules.
Frequent dose adjustment in C larify with the patient the link between treatment outcomes/goals and the dose regimen
warfarin therapy. (e.g. INR and warfarin dose).
R ecommend dose-administration aids.
S uggest the use of reminders, e.g. a diary, alarms, text messages or telephone reminder
services, where available.
Ask carers (professional carer support and/or family/friends) to help the patient take
his/her medicine.
93
94
Table 1: Barriers to medicine adherence and treatment strategies (continued)
Forgetfulness Older patient Patient stops taking antihypertensive Recommend dose-administration aids or reminders, e.g. a diary, alarms, text messages or
Patient has a medicines when the prescriber says telephone reminder services, where available.
busy lifestyle that target BP has been achieved. Ask carers (professional carer support and/or family/friends) to help the patient take
Patient doesnt Patient doesnt understand medical his/her medicine.
understand terminology. Remind the patient of prescription repeat dates.
prescribers intentions Tell the patient how to deal with missed doses.
Choose times for taking medicines that correlate with the patients daily activities (e.g. meals).
Verify (during the professional consultation) the patients understanding of how and why he/
she should take the prescribed medicine.
H elp the patient understand health advice, particularly if he/she has language or
literacy difficulties.
Actively refer the patient to the initial treatment plan to confirm the duration and goals of
therapy, and how this relates to therapeutic monitoring.
Miscommunication Patient doesnt Patient stops taking antihypertensive Verify (during the professional consultation) the patients understanding of how and why he/
understand the medicines when the prescriber says she should take the prescribed medicine.
prescribers intentions that target BP has been achieved. H elp the patient understand health advice, particularly if he/she has language or
Patient cant read Patient doesnt understand medical literacy difficulties.
the directions on the terminology. Actively refer the patient to the initial treatment plan to confirm the duration and goals of
medicine label therapy, and how this relates to therapeutic monitoring.
Patient cant identify Use larger print on dispensing labels.
the strength of tablets Use larger print for CMI.
(e.g. warfarin)
Facilitate the use of tactile prompts on product packaging (e.g. bubble stickers,
colour-coded stickers or ribbed pill containers).
Ask carers (professional carer support and/or family/friends) to help the patient take
his/her medicine.
95
96
Table 1: Barriers to medicine adherence and treatment strategies (continued)
Lack of self-efficacy Patient doesnt Patient doesnt believe that he/she Refer patient to self-management programs that include educational and
believe he/she can can achieve target BP or lipid levels. behavioural components.
reach the goals set by Set achievable goals (e.g. BP level) for the patient to work towards, and give positive
the prescriber feedback when he/she achieves targets.
Counsel the patient constructively and non-judgementally.
See the patient regularly to review his/her health.
Poor health literacy Patient doesnt Patient doesnt understand the Give the patient simple instructions about his/her medicines. This is especially important for
understand key importance of reaching his/ people with poor literacy and older people.
information about her target BP to help reduce Make sure that patient information is culturally and linguistically appropriate.
taking his/her cardiovascular risk. Verify (during the professional consultation) the patients understanding of how and why he/
medicines and the she should take the prescribed medicine.
importance of the
medicines in the short
and long term
Suboptimal Prescriber is unable H ealth professional to improve active listening skills (see module 3).
interpersonal skills of to assess the U se open-ended questions to assess the patients understanding.
the health professional patients beliefs and L isten and respond to the patients concerns.
understanding of
Adopt a non-judgemental attitude.
medicines and/or
disease
Pharmacist is
unable to assess the
patients beliefs and
understanding of
medicines and/or
disease
Health professionals Health professionals Health professional is unaware Health professional should reflect on and develop appropriate communication skills.
have suboptimal are unable to of his/her impact on the patients
interpersonal skills communicate or behaviour.
facilitate discussion
with the patient
Health professionals Health professionals Health professional is not familiar R eflect on and address health professional knowledge gaps.
lack of knowledge and dont engage with with current treatment guidelines Improve communication with other local health professionals and service providers to
training on managing available services (e.g. for reducing risk in heart establish referral processes.
chronic diseases Health professionals disease, management of chronic Identify efficient reference sources to keep informed of practice and guidelines changes (e.g.
are unaware of current heart failure). Heart Foundation guidelines, NPS).
treatment guidelines Health professional doesnt refer
the patient to available review or
support services (e.g. HMR, disease
self-management services, clinics).
Patient lacks confidence Patient belief that Develop interpersonal and communication skills to establish rapport with the patient.
in the pharmacist repeat prescriptions Make sure patients are familiar with their treatment plans and agree with the prescriber
are dispensed without about them. Give positive reinforcement.
assessing his/her need Reflect on and address knowledge gaps.
Patient belief that
the information the
pharmacist gives is
not accurate and/
or is different to
information the
prescriber gave
Patient has poor access Patient is immobile Ask family/friends or carers to help the patient access the prescriber.
to prescriber Patient has poor access Arrange help from home and community care services.
to public transport Arrange mobile clinic or home follow-up services, where available.
Patient lives in a rural Arrange home visits, where provided.
or remote area U se telehealth services, where available.
99
100
Table 1: Barriers to medicine adherence and treatment strategies (continued)
Patient has poor access Patient is immobile Ask family/friends or carers to help the patient access the pharmacy.
to pharmacy Patient has poor access Arrange help from home and community care services.
to public transport Arrange mobile clinic or home follow-up services, where available.
Patient lives in a Arrange home visits, including medicine delivery, where provided.
rural or remote area U se telehealth services, where available.
U se mail order/internet pharmacy for medicine supply, where available.
Patient misses Patient doesnt make or keep P
rompt the patient with written reminders, phone calls, text messages or emails.
appointments appointments with general
practitioner (GP).
Patient doesnt get repeat
prescriptions filled.
Patient has multiple Patient consults Arrange an HMR to clarify total medicine use.
prescribers different prescribers for E xplain to the patient the importance of using a limited number of health professionals,
different disease states especially in primary care.
Patient consults D evelop integrated electronic records.
different prescribers U se communication tools to keep track of therapeutic regimen changes (e.g. MediList,
because of frequently medicine diaries).
changing place of
residence
Lack of continuity
because health
professionals work
part time
A complete medical
record may not be
available at the time
of consultation
Patient sees
multiple GPs
Patient visits multiple Visiting different Pharmacist dispensing Arrange an HMR to clarify total medicine use.
pharmacies pharmacies leads cardiovascular medicines may not Explain to the patient the importance of using a limited number of health professionals.
to an incomplete know about other medicines the Use communication tools to keep track of therapeutic regimen changes and/or medicines
medicine history patient is taking that may interact or purchased or dispensed elsewhere (e.g. MediList, medicine diaries).
affect cardiovascular management.
Encourage the patient to get the health professional to update his/her MediList at each visit.
Pharmacist may not know if the
Encourage the patient to play an active role in his/her medicine management (refer to the
patient is also taking over-the-counter
NPS consumer guide to taking medicines and questions to ask health professionals).5
or complementary medicines.
Adapted from the World Health Organization, Pharmaceutical Society of Australia and Faculty of Pharmacy, University of Sydney.
References
1. World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization, 2003.
2. Jackson S, Naunton M, Peterson G. Essential CPE: Medication Adherence. Canberra: Pharmaceutical Society of Australia, 2006.
3. Aslani P, Benrimoj SI. Patient adherence and concordance counselling service. Sydney: The University of Sydney, 2000.
4. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986; 24: 6774.
5. National Prescribing Service. How to talk to your doctor or pharmacist. Canberra: National Prescribing Service, 2007. Available at: www.nps.org.au/consumers/publications/factsheets/
factsheets/get_to_know_your_medicines/how_to_talk_to_your_doctor_or_pharmacist. Accessed 17 January 2011.
102 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Table 2: Adherence to
cardiovascular medicines
Hypertension medicines
Drug class1 Common long-term adverse Rates of adherence/persistence
effects of drug classes2,3
Angiotensin- cough (1020% of patients) 45% of patients persisted with all ACEI at 33 months
converting enzyme headache median persistence = 23 months
inhibitors (ACEI) fatigue 18% failed to collect second prescription4
Angiotensin II receptor dizziness, headache 47% of patients persisted with ARA at 33 months
antagonists (ARA) median persistence = 26 months
18% failed to collect second prescription4
Beta-blockers lethargy 46% of patients consistently took beta-blockers
cold extremities six to 12 months after diagnosis of coronary
decreased exercise tolerance artery disease5
depression
nightmares
erectile dysfunction
Calcium channel headache 31% of patients persisted with all CCBs at 33 months
blockers (CCB) oedema median persistence = seven months
constipation (not all CCBs, 28% failed to collect second prescription4
mainly verapamil)
flushing
Thiazide and dizziness 38% of patients persisted with thiazides
related diuretics gout 12 months after initiation6
muscle cramps
inconvenient timing of diuresis
Angina medicines
Drug class1 Common long-term adverse Rates of adherence/persistence
effects of drug classes2
Nitrates headache n/a
flushing
tolerance
contact dermatitis (patches)
Nicorandil headache n/a
flushing
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 103
Table 2: Adherence to cardiovascular medicines (continued)
Arrhythmia medicines
Drug class1 Common long-term adverse Rates of adherence/persistence
effects of drug classes2
Amiodarone nausea n/a
constipation
disturbances to taste
skin pigmentation
headache
nightmares
Digoxin nausea n/a
diarrhoea
visual disturbances
nightmares
Dyslipidaemia medicines
Drug class1 Common long-term adverse Rates of adherence/persistence
effects of drug classes2
Statins myalgia (0.1% of users) 25% of patients were adherent after two years in
headache (49% of users) primary prevention
gastrointestinal disturbances 40% of patients with acute coronary syndrome
(5% of users)7 were adherent after two years
36% of patients with chronic coronary artery
disease were adherent after two years7
Fibrates dyspepsia (20% of users) n/a
abdominal pain (10% of users)
diarrhoea (7% of users)7
Ezetimibe headache n/a
diarrhoea
104 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Table 2: Adherence to cardiovascular medicines (continued)
Antiplatelet medicines
Drug class1 Common long-term adverse Rates of adherence/persistence
effects of drug classes2
Aspirin gastrointestinal irritation 71% of patients persisted with aspirin use
bleeding six to 12 months after diagnosis of coronary
artery disease5
Clopidogrel diarrhoea n/a
bleeding
Dipyridamole headache n/a
diarrhoea
nausea
hot flushes
References
1. Rossi S. Australian Medicines Handbook. South Australia: Newstyle Printing, 2009.
2. Therapeutic Guidelines: Cardiovascular (2008). In: eTG complete (CD-ROM). Melbourne: Therapeutic Guidelines
Limited, 2009.
3. Luxford M, Lockney AL. Cardiovascular Disease Part 2: Hypertension. Deakin: Pharmaceutical Society of
Australia, 2002.
4. Simons LA, Ortiz M, Calcino G. Persistence with antihypertensive medication: Australia-wide experience,
20042006. Med J Aust 2008; 188:224227.
5. Newby LK, LaPointe NM, Chen AY, et al. Long-term adherence to evidence-based secondary prevention therapies
in coronary artery disease. Circulation 2006; 113:203212.
6. Bloom BS. Continuation of initial antihypertensive medication after 1 year of therapy. Clin Ther 1998; 20:671681.
7. Luxford M, Lockney AL. Cardiovascular Disease Part 1: Cholesterol. Deakin: Pharmaceutical Society of
Australia, 2002.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 105
Notes
106 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Case study 1
Learning objectives
After completing this case, you should be able to:
recognise the value of a patients dispensed medicine history as one indicator of
medicine-taking behaviour
apply appropriate communication skills and strategies to obtain information about the barriers to
adherence to medicine
appropriately educate patients to correct misconceptions about the need for medicines
explain the complementary roles of general practitioners (GPs), pharmacists and practice nurses
in identifying and addressing non-adherence to medicine
describe the best interdisciplinary approach for the ongoing monitoring of adherence to medicine.
Mr AB is a 45-year-old real estate agent who lives with his wife. He has smoked one packet of cigarettes
a day since his teens, and consumes, on average, two standard alcoholic drinks per day. Six months ago,
he went to his GP for a check-up for an insurance policy. Dr GB, his GP, was concerned that Mr ABs
blood pressure was high (155/95 mmHg). Blood tests revealed that his lipids were also elevated.
Dr GB gave Mr AB dietary and lifestyle advice. Mr AB went back to see Dr GB for a review three
months later.
After three months, Mr AB had lost 5 kg after following a low fat diet and going to the gym five
nights a week for about 30 to 45 minutes each time. His blood pressure was 150/95 mmHg, TC level
was 6.2 mmol/L, LDL-C level was 4.5 mmol/L, HDL-C level was 0.9 mmol/L, TG level was 1.8 mmol/L
and TC:HDL ratio was 6.9.
Dr GB explained to Mr AB that he was at high risk of developing cardiovascular disease and
recommended starting perindopril arginine 2.5 mg and atorvastatin 20 mg. He also suggested that Mr
AB consider quitting smoking, because this would reduce his cardiovascular risk more. Mr AB agreed
to start treatment and come back to see Dr GB in one month.
At the follow-up appointment, one month after starting the medicines, Mr AB reported no problems with
the medicines. Dr GB increased the dose of perindopril to 5 mg daily, because Mr ABs blood pressure
was still too high.
Two months later, Mr AB went to his pharmacy with a prescription from the medical centre near
his work for medicine to treat an eye infection. He is a regular customer at the pharmacy, and the
pharmacist remembered helping him with nicotine-replacement therapy a few weeks before. She
dispensed the prescription for chloramphenicol eye drops.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 107
As part of the dispensing process, the pharmacist reviews Mr ABs dispensing history on the pharmacy
computer and notes the following.
Three months ago: p erindopril 2.5 mg, one in the morning m30
atorvastatin 20 mg, one in the morning m30
Two months ago: perindopril 5 mg, one in the morning m30 and repeat x 2
atorvastatin 20 mg, one in the morning m30 and repeat x 2
Hi, Mr AB. You are looking great these days. Youve lost a lot of Follow up on previous
weight. How are you going with the nicotine patches? intervention using an open-
ended question. Example of
Its been a bit rough. I have cut back, but I still enjoy a smoke with
positive reinforcement.
a beer after work. Im enjoying my morning run much better these
days. Evelyn is thinking of quitting now, too.
Thats a great start! Positive reinforcement
When you are ready for the next stage, well look at trying to get Establishing a treatment goal
you off them for good.
Cutting back on the cigarettes, doing regular physical activity and Reinforcing positive behaviour
the medicines will help you to reach your targets.
How are you going with the new medicines? Open-ended question to
check adherence
Everythings fine.
Thats good, Mr AB. Before you go, do you need another Response to the trigger,
repeat dispensed today or have you already picked them up which may indicate an
from another pharmacy? adherence issue. Use of
non-judgemental language
No, I dont need them anymore. I have decided to let them go
for a while.
Oh, okay. What made you decide to let them go for a while? Open-ended question to
explore adherence barrier
I just dont think its necessary. Now that Ive cut back on the The pharmacist has identified
cigarettes and lost some weight, I feel much fitter. an adherence barrier and
recognises a need for action
Discussion point
What action could the pharmacist take at this stage?
108 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
The pharmacist needs to find out if Dr GB knows that Mr AB has stopped taking his medicines.
Mr AB, I know you are in a rush, but can you spare a few Request to engage
more minutes?
Okay.
What did you mention to the doctor this morning about stopping Establishing whether or
your tablets? not prescriber is aware of
the non-adherence
I saw a different doctor and he seemed very busy. I didnt mention
it. I didnt think it was important.
The pharmacist needs to find out what Mr AB understands about why his GP has prescribed these
medicines. She probably wouldnt have access to Mr ABs lab results or blood pressure readings.
Yes, they seem very busy at the medical centre these days. Exploring patient knowledge
Before you started these medicines, what did Dr GB tell you about medical condition
about why you should take them? and treatment
Just that my blood pressure was a bit high and so was my cholesterol.
He seemed concerned that I lost my father to a heart attack. I dont
think this is relevant to me Dad was 63 when he died and Im
only 45. I dont want to be taking pills for the rest of my life.
It seems like you are unconvinced about taking the medicines. Reflective listening
What concerns you exactly? Exploring patient beliefs
Its just a hassle to take pills every day, and I dont want to get
into that.
What exactly makes it a hassle for you? Further exploring
adherence barrier
I just dont want to have to think about it every day.
I can understand that. When youre not used to taking tablets, it Suggesting adherence strategy
can be a hassle. Perhaps you could make it part of your morning
routine, say, taking them before you shower?
I guess so.
The pharmacist concludes from the duration of Mr ABs latest prescription (one months supply with
two repeats) that Dr GB would want to review his treatment three months after the last consultation
(i.e. in one months time). The pharmacist believes it is important for Dr GB to be aware of the current
situation and address Mr ABs concerns. As Mr AB is not taking his medicines, he may not return to his
GP for follow up as planned.
The pharmacist needs to encourage Mr AB to return to his GP as soon as possible, so that the barriers
to taking his medicines can be identified and managed.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 109
I think that Dr GB would consider it very important for you to keep Reinforcing the risk of
taking your medicines, because high blood pressure and cholesterol non-adherence and supporting
can put you at risk of heart disease, even at your age. other health professional
I think that he probably wants to see you in the next month to Strategy to initiate resolution
check how things are going, but maybe you should make an of adherence issue
appointment a bit sooner to talk to him about your concerns.
To save you some time, you can use our phone and arrange an Facilitating action
appointment now.
The pharmacist makes a note in the pharmacy dispensing software to speak to Mr AB the next time he is
at the pharmacy so that she can follow up on whether or not he:
has been back to his GP
is taking his medicines
wants to clarify any information about his medicine or condition.
Discussion points
What is the role of the pharmacist in this situation?
What systems should the pharmacy have in place to identify problems with adherence to medicines?
Is the current infrastructure adequate for identifying and monitoring adherence issues?
Should this situation have been handled differently? What other options did the pharmacist have?
Was the dialogue between this patient and pharmacist appropriate?
What are the barriers and facilitators to interprofessional collaboration? For example, to the
pharmacist discussing this patients situation with the GP?
Dr GB needs to explore Mr ABs reasons for not adhering to his medicine management plan and find out
exactly what the barriers are.
110 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Discussion points
What questions could the GP ask to find out why this patient is not taking his medicines?
What questions could the GP ask to find out if there are other barriers to taking medicine?
Should the GP have handled this differently?
Dr GB acknowledges that Mr AB has adhered to his healthy eating and physical activity regimen, as
demonstrated by his 5 kg weight loss and his efforts to quit smoking. Dr GB might reinforce this by asking
if Mr AB would like more information about quitting smoking and support organisations.
Dr GB needs to address Mr ABs concerns and make sure that Mr AB understands the consequence of not
taking his medicines.
Dr GB shows Mr AB the Australian cardiovascular risk tables (see next page). Dr GB shows him that
because of his blood pressure and lipid levels, and because he still smokes, he has a moderately high
(1619%) risk of developing cardiovascular disease within the next five years. He uses the tables to
demonstrate to Mr AB how, by reducing his blood pressure and/or lipid levels, his risk will be reduced,
and that quitting smoking will reduce his risk even more.
Discussion points
How would you explain Mr ABs cardiovascular risk to him?
How would you explain to Mr AB the reasons why he should keep taking his medicines?
How could the GP deal with Mr ABs reasons for not taking his medicines?
How would you handle this situation?
During the consultation, Dr GB convinces Mr AB that taking medicines to lower his blood pressure and
lipid levels is necessary. Mr AB agrees to a management plan that includes:
re-starting his medicines
making an appointment with Dr GB in one month so they can discuss his progress and any problems
he may have
continuing with his efforts to quit smoking
continuing with his healthy eating and physical activity regimen.
With Mr ABs permission, Dr GB will contact the pharmacist to:
request that she monitor Mr ABs adherence to his medicines
give Mr AB the relevant Consumer Medicine Information (CMI) and explain it to him
reinforce to Mr AB information about nicotine replacement therapy and quit smoking support groups.
Dr GB will also ask the practice nurse to:
remind Mr AB about future doctors appointments by phoning him
monitor Mr ABs blood pressure when he is next in
help Mr AB to quit smoking.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 111
112
Australian cardiovascular risk charts
Peoplewithoutdiabetes How to use the risk charts Peoplewithdiabetes
1. Identify the chart relating to the persons sex, diabetes status,
Women Men Women
smoking history and age. The charts should be used for all adults Men
Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker
aged 4574 years (and all Aboriginal and Torres Strait Islander
179* 179* 179* 179*
adults aged 35 years or older) without known history of CVD or
160 Age 160 160 Age 160
6574 already known to be at high risk. 6574
140 140 140 140
120 120 120
2. Within the chart, choose the cell nearest to the persons age, 120
systolic blood pressure (SBP) and total cholesterol (TC):HDL
179* 179* 179* 179*
Age
ratio. For example, the lower left cell contains all non-smokers
Age
160 160 160 160
5564 without diabetes who are 3544 years and have a TC:HDL 5564 ratio
140 140 140 140
of less than 4.5 and a SBP of less than 130 mmHg.
120 120 120 120
179* 179*
3. The colour of the 179
cell* that the person falls into provides their 179*
160 Age 160
5-year absolute cardiovascular
160
risk level (see legend for
Agerisk 160
140 4554 140
who fall exactly on a threshold between
category). People 140 4554 cells 140
Systolicbloodpressure(mmHg)
Systolicbloodpressure(mmHg)
Systolicbloodpressure(mmHg)
are placed in the cell indicating higher risk.
120 120 120 120
After his appointment with Dr GB, Mr AB calls into the pharmacy to have his prescriptions dispensed.
Hi, Mr AB. Its good to see that you went back to your GP. Positive reinforcement
What did he tell you about your medicines? Eliciting the patients
understanding
He really made me realise that if I dont take them now, I stand
a fair chance of getting heart disease in the next five years,
especially because my dad had it.
Im sure youll get into a routine. You could take them both when Providing a strategy
you get up in the morning. You can make it part of your morning for adherence
routine. For example, take them straight after breakfast, so you
wont forget to take them.
Ill just go through the information sheets I have printed out for Providing patient education
you. It will only take a few minutes. and checking understanding
That would be good. All the information looked a bit daunting
last time. I also need some more nicotine patches. Its hard, but I
realise that I really should quit.
I know. Its difficult for everyone. Ill also give you details of Providing education
support phone numbers that you can call if you need help. and support
Mr AB, your new scripts are only for one months supply. This Reinforcing the need for action
means that Dr GB wants to see you again before the month is up. and confirming follow up
Have you made another appointment?
Yes, I did before I left the surgery. Thanks for the information.
Ill let you know how I get on.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 113
Discussion points
Were the actions of the pharmacist appropriate?
Is there anything the pharmacist should have done differently?
What systems should the pharmacy have in place to monitor adherence to medicines?
What is the best way for the GP, pharmacist and practice nurse to communicate regarding follow
up for Mr AB?
What are the roles of the GP, pharmacist and practice nurse in the ongoing management of this
patients adherence to medicines?
114 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
More information and resources
Australian Government Department of Health and Ageing. Every cigarette is doing you damage.
Canberra: Australian Government Department of Health and Ageing, 2010. Available at:
www.quitnow.info.au. Accessed 10 January 2011.
Australian Government Department of Health and Ageing. Smoking Cessation Guidelines for Australian
General Practice. Practice handbook 2004. Canberra: Australian Government Department of Health
and Ageing, 2004. Available at: www.health.gov.au/internet/main/publishing.nsf/Content/6F8B2F83E43
9599BCA256F1900045114/$File/smoking_cessation.pdf. Accessed 11 January 2011.
National Heart Foundation of Australia. Australian cardiovascular risk charts. Melbourne: National
Heart Foundation of Australia, 2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/
aust-cardiovascular-risk-charts.pdf. Accessed 11 January 2011.
National Heart Foundation of Australia. Healthy eating and drinking tips. Melbourne: National
Heart Foundation of Australia, 2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/
Healthy-Eating-Tips-2009-05.pdf. Accessed 11 January 2011.
National Heart Foundation of Australia (Aslani P, Krass I, Bajorek B, Thistlethwaite J, Tofler G on behalf of
the Heart Foundation Pharmaceutical Roundtable). Module 3: Creating concordance and making shared
treatment decisions. In: Improving adherence in cardiovascular care. A toolkit for health professionals.
Melbourne: National Heart Foundation of Australia, 2011.
National Prescribing Service. Prescribing Practice Review Twenty: Smoking cessation. Canberra: National
Prescribing Service, 2002. Available at: www.nps.org.au/__data/assets/pdf_file/0009/16947/ppr20.pdf.
Accessed 11 January 2011.
National Vascular Disease Prevention Alliance. Absolute cardiovascular disease risk assessment.
Quick reference guide for health professionals. Melbourne: National Vascular Disease Prevention
Alliance, 2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/absolute-risk-
assessement.pdf. Accessed 11 January 2011.
National Vascular Disease Prevention Alliance. Online cardiovascular disease risk calculator.
Melbourne: National Vascular Disease Prevention Alliance, 2010. Available at: www.cvdcheck.org.au.
Accessed 11 January 2011.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 115
Notes
116 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Case study 2
Learning objectives
After completing this case, you should be able to:
explore patients health beliefs as barriers to adherence to medicines
consider non-adherence to medicine as a potential cause of suboptimal/non-response to treatment
clarify patients perceptions of side effects
recognise the complementary roles different health professionals can play in monitoring and
managing adherence to medicines.
Ms CD, aged 64, is a retired public servant who has a routine appointment with Dr RS, her general
practitioner (GP). Ms CD does not drink, has never smoked and prefers organic foods. She enjoys
gardening and baking. Since she was diagnosed with type 2 diabetes three years ago, she has modified
her diet, lost weight and follows a healthy eating plan. She does regular moderate-intensity physical
activity, including walking and swimming regularly. Ms CD believes in complementary medicines and
sees a counsellor to manage depression.
Today, she attends the surgery for a routine blood pressure check.
Discussion point
What information is required from the patient?
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 117
Good morning, Ms CD. How can I help you today?
I just came for my regular blood pressure check.
Discussion point
What possible factors could be contributing to this patients lack of response to
antihypertensive medicines?
Ms CD, your blood pressure is still a little high. I was hoping that your new medicine would bring your
blood pressure down more than it has. How are you getting on with the tablets?
Okay. I started the new tablets after my last visit.
Could you tell me how you take your blood pressure medicines?
I take them in the morning.
Is that every morning?
Well, maybe not every morning.
Okay. How many days would you miss in an average week?
Im not sure.
So would you take them 50% of the time?
Lately, I havent taken them so often.
Why is that?
I guess I didnt feel like it.
Could you tell me how you are feeling?
A bit down at the moment.
Do you want to talk about whats making you feel down?
I dont know. I just feel down from time to time.
Can I help you with this?
Not really. I see a counsellor and that helps a bit. To tell the truth, I prefer to take some natural
medicines to give me a boost when Im feeling down. Im concerned that the blood pressure pills
make the down days worse.
Do you think they are affecting your mood?
Maybe. The pamphlet in the packet said they may make me feel tired.
118 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Have you been feeling worse since you started taking the blood pressure tablets?
Yes. I think it did get worse around that time. Ive tried not taking any of the blood pressure pills to see if
it makes a difference.
And do you think it helps?
Pills dont agree with me. I know I have to take the diabetes ones, but would really prefer to find a
natural solution.
I can see that you prefer not to take the medicines. What advice has your counsellor given you?
I havent really discussed my blood pressure and diabetes with her. She just helps me cope with
feeling down.
Can you tell me what natural or complementary medicines you take?
I just take something for general wellbeing.
So you are not taking either of your blood pressure medicines because you think they have a negative
effect on your mood and you dont really like taking medicines anyway.
Yes. I know you wouldnt agree, but I just prefer to have natural things.
You need to be comfortable with your treatment, so we need to find a solution that is right for you.
That sounds like a good idea.
Dr RS refers to an electronic resource on her computer and sees that depression or mood changes
are not listed side effects in the class statement for angiotensin-converting enzyme (ACE) inhibitors,
indapamide or metformin.
Dr RS can see that the most likely reason why Ms CDs blood pressure is not responding is because she is
partially non-adherent to her antihypertensive medicines.
Dr RS:
reassures Ms CD that her antihypertensive medicines are unlikely to affect her mood
finds out what Ms CD knows about the risks of not lowering her blood pressure
tells Ms CD that because she is aged over 60 years, has diabetes and high blood pressure, she has a
high risk of developing cardiovascular disease
explains to Ms CD that by reducing her blood pressure, she can lower her overall absolute risk
discusses with Ms CD the potential risks versus the benefits of taking the medicine.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 119
120
Australian cardiovascular risk charts
Peoplewithdiabetes How to use the risk charts
1. Identify the chart relating to the persons sex, diabetes status,
Women Men smoking history and age. The charts should be used for all adults
Non-smoker Smoker Non-smoker Smoker
aged 4574 years (and all Aboriginal and Torres Strait Islander
179* 179* Adultsovertheageof
60withdiabetesare adults aged 35 years or older) without known history of CVD or
160 Age 160
6574 equivalenttohighrisk already known to be at high risk.
140 140
(>15%),regardless
120 120 oftheircalculatedrisk 2. Within the chart, choose the cell nearest to the persons age,
level.Nevertheless, systolic blood pressure (SBP) and total cholesterol (TC):HDL
179* 179* reductionsinrisk
Age
ratio. For example, the lower left cell contains all non-smokers
160 160 factorsinthisage
5564 groupcanstilllower with diabetes who are 3544 years and have a TC:HDL ratio of
140 140
overallabsoluterisk. less than 4.5 and a SBP of less than 130 mmHg.
120 120
179* 179*
3. The colour of the cell that the person falls into provides their
160 Age 160
5-year absolute cardiovascular risk level (see legend for risk
140 4554 140
category). People who fall exactly on a threshold between cells
Systolicbloodpressure(mmHg)
Systolicbloodpressure(mmHg)
120 120
are placed in the cell indicating higher risk.
179* 179* Notes: The risk charts include values for SBP alone, as this is the most informative
Chartsinthisage
of conventionally measured blood pressure parameters for cardiovascular risk. For
in 160 Age 160 bracketareforusein certain groups CVD risk may be underestimated using these charts; please see page 3
es 140 3544 140 AboriginalandTorres of Absolute cardiovascular disease risk assessment quick reference guide for health
StraitIslander professionals for recommendations.
120 120
populationsonly. CVD refers collectively to coronary heart disease (CHD), stroke and other vascular disease
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
including peripheral arterial disease and renovascular disease.
Totalcholesterol:HDLratio* Totalcholesterol:HDLratio* Charts are based on the NVDPAs Guidelines for the assessment of absolute cardiovascular
disease risk and adapted with permission from New Zealand Guidelines Group. New
Zealand Cardiovascular Guidelines Handbook: A Summary Resource for Primary Care
* In accordance with Australian guidelines, patients with systolic blood pressure 180 mmHg, Practitioners. Second edition. Wellington, NZ: 2009. www.nzgg.org.nz.
oratotalcholesterolof>7.5mmol/L,shouldbeconsideredatincreasedabsoluteriskofCVD. These charts are taken from Absolute cardiovascular disease risk assessment quick reference
guide for health professionals. 20092011 National Heart Foundation of Australia.
Risklevelfor5-yearcardiovascular(CVD)risk
Highrisk Moderaterisk Lowrisk
Discussion points
What are the barriers to Ms CDs adherence to her medicines?
What strategies would be appropriate to manage the barriers Ms CD has to adhering to her medicines?
What questions should the GP ask Ms CD to find out what she believes about Western medicines
and on what her beliefs are founded?
How can the GP explore what type of counselling Ms CD is having?
What strategy can the GP use to find out more about Ms CDs belief about taking Western versus
complementary medicines?
How should the GP explain to Ms CD about high cardiovascular disease risk and the benefits of
reducing her blood pressure?
What strategies can the GP use to find out if mood change is a real or perceived side effect?
Ms CD, just like with the diabetes, it is important that we control your blood pressure to prevent
problems in the future.
Yes, I realise that, but I dont want to take pills that will make me feel bad.
I have checked and it is unlikely that your blood pressure tablets are affecting your mood. However, we
need to make sure that this is the case with you. How would you feel about taking just the fosinopril to
start with and we can monitor your mood, perhaps by using a diary?
I guess I could try it.
Okay, thats good. Lets try taking them for one week and I will ring you to find out how you are going.
Would that be okay?
Im willing to try, but I dont want to keep taking them if they make me feel down.
I can understand that. If everything is okay when I ring you next week, perhaps you could make an
appointment for two weeks time and we can discuss how your mood has been and whether or not we
need to find an alternative that you are happy with. How does that sound?
Okay. I guess thats the only way to find out if the pills are affecting me or not.
Dr RS rings Ms CD a week after their consultation and discovers that she is taking her fosinopril 20 mg
in the morning on a regular basis. She is also keeping a diary of her mood and any other issues that
concern her. She has made an appointment to see Dr RS in a weeks time and agreed to continue taking
the tablets and bring her diary to the consultation.
Discussion points
How would you approach the conversation with this patient? What information would you need to
gather? What questions would you ask? What else could be done?
Would a Home Medicines Review (HMR) be helpful?
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 121
Hello, Ms CD. How have you been feeling since I saw you last?
Not too bad. I have been taking the tablets regularly and keeping a note of how Ive been feeling,
like you said.
Thats good. Lets see how your blood pressure is going.
Dr RS still needs to determine if the complementary medicines that Ms CD takes are likely to interact
with her Western medicines.
Dr RS is aware that a HMR can help to find out:
how patients actually take their medicines at home
the level of adherence to medicines from a patients dispensing history
what over-the-counter or complementary medicines are being used
any possible interactions between Western, complementary and over-the-counter medicines.
Dr RS knows that a HMR is a Medicare item (900) and can be offered to any patient if a GP feels it is
necessary to ensure Quality Use of Medicines (QUM) or to address patient needs. Although Ms CD takes
fewer than five regular medicines, she does exhibit some risk factors known to predispose people to
medicine-related problems, namely:
subtherapeutic response to treatment with medicines
non-adherence.
Dr RS discusses the benefits of a HMR with Ms CD. She agrees that it would help her strike a balance
between the need to manage her prescribed Western medicines and her desire to take complementary
medicines. Dr RS points out that the pharmacist who undertakes the HMR will be able to identify which
complementary medicines might be better suited to her Western medicine regimen to avoid interactions.
Dr RS obtains Ms CDs consent to give the pharmacist doing the review the relevant information. She
prints a referral for a HMR that will be sent to the pharmacy of Ms CDs choice.
Ms CD agrees to Dr RSs suggestion to have a HMR. She agrees to keep taking her prescribed
Western medicines regularly and keep a diary of her mood. She also says she will make another
appointment with Dr RS in one month so that they can discuss the pharmacists review report and
agree on a medicine management plan.
Dr RS asks the practice nurse or receptionist to:
forward the HMR referral to Ms CDs pharmacy
tell her when the pharmacists HMR report is received
call Ms CD in one month to remind her of her appointment.
Discussion points
Should the GP have used other communication strategies to explore Ms CDs beliefs and attitudes
towards her antihypertensive medicines?
How could the GP explore Ms CDs acceptance of taking her metformin, but not her
antihypertensive medicines?
What are the potential risks of non-adherence to medicines and how could the GP explain these?
Should the GP have dealt with the situation differently?
122 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
On receipt of the HMR referral, the pharmacys accredited pharmacist contacts Ms CD to make an
appointment to visit her at home and discuss her medicines within the next few days.
The pharmacy tells Dr RS the arrangements for the review and contact details of the accredited
pharmacist who will be conducting the review. Before the review, the accredited pharmacist:
notes Dr RSs reasons for the review
reviews Ms CDs dispensing history to get information about her adherence
notes questions she will ask Ms CD regarding her Western, complementary and over-the-counter
medicines, any side effects she may have and the timeline of any side effects to see if they are medicine
or disease related.
Two days later, the accredited pharmacist visits Ms CD at home. She:
discusses Ms CDs beliefs about her antihypertensive medicines and the association she has made with
her feeling of depression
identifies issues Ms CD may have with her medicines; for example, adherence, storage or administration
determines which complementary medicines Ms CD is taking and if they are likely to interact with her
Western medicines.
After the interview, the accredited pharmacist clinically assesses the information gathered from
Dr RSs referral and the interview with Ms CD. She then writes a report that includes her findings
and recommendations.
The following day, the accredited pharmacist sends the review report to Dr RS. The report:
confirms that Ms CD believed her antihypertensive medicines contributed to her depressed mood
and that she had stopped taking them for periods of up to a week (however, she has been taking them
regularly over the past few weeks)
identifies the complementary medicines Ms CD takes (multivitamin supplements)
finds no interaction between Ms CDs complementary and Western medicines
confirms that the complementary medicines Ms CD takes are unlikely to affect her mood.
Dr RS rings the accredited pharmacist to discuss the findings outlined in the report.
Three weeks later, Ms CD returns to Dr RS as planned.
Discussion point
How would you talk to this patient about her review results?
Ms CD, I have spoken to the pharmacist about your medicines. Shall we talk about what she said?
Yes. She gave me some useful information and told me that it is unlikely the pills are making me
depressed. She also reassured me that the vitamin tablets I take wont react with my pills.
First, Dr RS and Ms CD discuss the possibilities for managing her mood and agree on a
non-pharmacological strategy.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 123
At your last visit, we agreed to come up with a plan to manage your medicines that you are happy with.
Yes, I remember.
Shall we agree that you will try taking the tablets regularly for the next month, and then you can come
back and tell me how you are getting on?
Yes. That seems fine.
In the meantime, if you have any side effects that you think may be due to the medicines, have a chat to
the pharmacist about them.
That sounds good.
Discussion points
What are the benefits of having a medication management plan?
What are the benefits of this patient keeping a copy of her medication management plan?
What are the benefits of the pharmacy having a copy of Ms CDs medication management plan?
What follow up would be appropriate?
The GP:
monitors Ms CDs progress towards her treatment goals
makes sure she sees Ms CD for regular follow up.
The practice nurse:
reminds Ms CD of her appointments
advises Ms CD about home blood pressure monitoring.
The community pharmacist:
keeps a copy of Ms CDs medication management plan
monitors Ms CDs ongoing adherence by checking the dispensing history in the pharmacy computer
advises Ms CD about using complementary medicines in combination with Western medicines.
124 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Discussion points
What were the barriers to adherence in this case?
What other strategies could have been used to address adherence in this case?
What systems should the pharmacy and GP practice have in place to monitor adherence?
What is the best way for the GP, pharmacist and practice nurse to communicate about following
up with this patient?
What are the roles of the GP, pharmacist and practice nurse in the ongoing management of
this patients adherence to medicines?
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 125
More information and resources
Australian General Practice Network. Home medicines review (HMR) and residential
medication management review (RMMR). Forrest, ACT: Australian General Practice Network,
2010. Available at: www.medicareaustralia.gov.au/provider/pbs/fourth-agreement/hmr.jsp and
www.medicareaustralia.gov.au/provider/pbs/fourth-agreement/rmmr.jsp. Accessed 10 January 2011.
Australian Government Department of Health and Ageing. Domiciliary medication management home
medicines review referral form 2967. Available at: www.health.gov.au/internet/main/publishing.nsf/Content/
5F080847D92025C3CA2573E100807F2A/$File/finaldmmrhmrform.pdf. Accessed 10 January 2011.
Australian Government Department of Health and Ageing. Domiciliary medication management review:
Medication management plan. Canberra: Australian Government Department of Health and Ageing, n.d.
Available at: www.health.gov.au/internet/main/publishing.nsf/Content/5F080847D92025C3CA2573E100
807F2A/$File/MMPlan.pdf. Accessed 10 January 2011.
Australian Government Department of Health and Ageing. Medication management review. Available
at: www.health.gov.au/internet/main/publishing.nsf/Content/medication_management_reviews.htm.
Accessed 24 January 2011.
Australian Government Department of Health and Ageing. Medication management reviews. Medicare
item 900, MBS online. Canberra: Australian Government Department of Health and Ageing, n.d.
Available at: www9.health.gov.au/mbs/search.cfm?q=900&sopt=S. Accessed 10 January 2011.
Diabetes Australia and Royal Australian College of General Practice. Diabetes Management in General
Practice. Guidelines for type 2 diabetes 2009/2010. Section 9.2 hypertension, diabetes management in
general practice guidelines for type 2 diabetes. Canberra: Diabetes Australia, 2009. Available at:
www.diabetesaustralia.com.au/PageFiles/763/Diabetes%20Management%20in%20GP%2009.pdf.
Last accessed 10 January 2011.
National Heart Foundation of Australia (Aslani P, Krass I, Bajorek B, Thistlethwaite J, Tofler G on behalf of
the Heart Foundation Pharmaceutical Roundtable). Module 3: Creating concordance and making shared
treatment decisions. In: Improving adherence in cardiovascular care. A toolkit for health professionals.
Melbourne: National Heart Foundation of Australia, 2011.
National Heart Foundation of Australia. Australian cardiovascular risk charts. Melbourne: National Heart
Foundation of Australia, 2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/aust-
cardiovascular-risk-charts.pdf. Accessed 10 January 2011.
National Heart Foundation of Australia. Guide to management of hypertension 2008. Quick reference
guide for health professionals. Updated December 2010. Melbourne: National Heart Foundation
of Australia, 2010. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/Guide-to-
management-hypertension-2008.pdf. Accessed 3 March 2011.
National Vascular Disease Prevention Alliance. Absolute cardiovascular disease risk assessment. Quick
reference guide for health professionals. Melbourne: National Vascular Disease Prevention Alliance,
2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/guidelines-Absolute-risk.pdf.
Accessed 10 January 2011.
126 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Case study 3
Learning objectives
After completing this case, you should be able to:
distinguish between intentional and non-intentional adherence to medicines
recognise post-discharge from hospital as a critical time to monitor adherence to medicines
identify the unique and complementary roles health professionals play in managing adherence
to medicines in people living in residential aged-care facilities
consider non-adherence to medicines as a sign of the need to review the level of care
provided/required in the aged-care facility.
Mrs FH is an 86-year-old widow. Since her husband died 10 years ago, Mrs FH has found it
increasingly difficult to manage at home on her own, especially with the steep steps to her front door
and a large garden to maintain. Mrs FH gave up driving when she was 80 years old, because she found
the increasing volume of traffic intimidating. Because she didnt live near public transport, Mrs FH
became increasingly isolated at home and found it difficult to do her shopping. About four years ago,
Mrs FH was assessed by an Aged Care Assessment Team (ACAT) and moved into Sunnybanks, a low-
care residential aged-care facility. She is a cheerful and independent woman who enjoys participating
in the social activities at Sunnybanks, especially the bridge club. Mrs FH has never smoked, and enjoys
a glass of wine with dinner. Her son is her only family, and he lives on the other side of the city. He
and his wife take Mrs FH out to lunch every other Sunday.
When Mrs FH moved to Sunnybanks, Dr VG, her general practitioner (GP), conducted a comprehensive
medical assessment. Dr VG noted the following in the assessment.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 127
The nurse is aware that Mrs FHs forgetfulness may impact on her care, in particular, on her ability to
manage her own medicines. She needs to determine if Mrs FH is becoming forgetful and if so, if this is
affecting adherence to her medicines regimen. The nurse needs to find out what medicines Mrs FH is
taking to determine whether non-adherence is an immediate concern.
Discussion points
How should the possible causes of Mrs FHs memory decline be assessed?
Could the decline in memory be attributed to the new medicines or dementia?
Is Mrs FHs current level of care appropriate?
The nurse checks Mrs FHs medicines record and sees that she has started taking new medicines,
including warfarin, since her return from hospital. The nurse knows warfarin needs careful administration
and monitoring. She remembers that the pharmacist is due to call at Sunnybanks that day and asks him to
check if Mrs FH is managing her medicines properly, and document his findings in her health record.
Discussion points
Was the action taken by the nurse appropriate?
What other action should be taken?
The pharmacist needs to determine what medicines Mrs FH is taking. He checks her health record to see
if there is any indication that she is not adhering to her regimen. He also sees that the latest recorded INR
result (two weeks ago) was 2.0.
The pharmacist speaks to Mrs FH that afternoon to see if she is having a problem with her medicines.
Hello, Mrs FH. Have you been enjoying a bit of sun out in the Establishing rapport
garden this afternoon?
Yes, the roses are lovely, but I do miss my garden sometimes.
I hear that you have come back from hospital recently and the Follow up on previous
doctors started you on some new tablets. Could I have a word with intervention using an open
you about them? ended question. Example
of positive reinforcement.
Yes, that would be fine. They are in my room. Ill show you.
Mrs FH, what did the doctor tell you about your medicines when Open-ended question
you were in hospital?
Just that I have two new pills for my heart. The pharmacist at the
hospital gave me information and a booklet, but I cant remember
everything she said.
Can you show me your new tablets and tell me how you take them?
Now, let me see. I take the white ones in the morning with
my other pills. Here are the coloured ones. She said to take
these after dinner.
And what about the other ones? Can you tell me how you take those?
128 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Mrs FH explains how she takes her other medicines.
How often do the nursing staff here ask you if you have taken your tablets?
Usually after dinner, but I often cant remember if Ive taken the pills or not, so I say just say yes.
Sometimes it is difficult to remember, especially when you take your pills every day.
I do find I forget things more easily these days, but thats just my age.
There are a number of ways we can help you remember to take your tablets. Perhaps we could have a
chat and work out the best way to help you take your pills at the right time every day.
The pharmacist records the details of his meeting with Mrs FH in her health record and informs the
Sunnybanks nurse. He needs to determine the extent of Mrs FHs non-adherence. He does this by
checking her dispensing history at the pharmacy that supplies Sunnybanks residents.
The pharmacist consults Mrs FHs health record and sees that she is due for her annual medicines review
(Residential Medication Management Review RMMR). This review is a high priority because of Mrs
FHs possible non-adherence to her medicines regimen, recent discharge from hospital, changes to her
medicines and because she is taking a medicine with a low therapeutic index that requires monitoring.
Discussion points
Were the actions of the pharmacist appropriate?
What other action should have been taken?
In the meantime, the pharmacist talks to the Sunnybanks nurse about his findings. The Sunnybanks
nurse contacts Dr VGs surgery and speaks to the practice nurse, who coordinates calls from aged-care
facilities. She asks the practice nurse to talk to Dr VG about a collaborative medicines review (MBS
Item 903) for Mrs FH and a case conference (MBS Items 735, 739, 743) between Dr VG, Sunnybanks
staff, the pharmacist and the physiotherapist.
In the meantime, the Sunnybanks nurse assesses Mrs FHs ability to self-medicate.
Discussion points
Were the actions taken to manage this situation appropriate?
What is the advantage of nominating a GP practice member to liaise with aged-care facilities?
Mrs FH is consulted and agrees to a case conference, which is planned for the following week.
At the case conference, the pharmacists findings and the nurses assessment of Mrs FHs ability to self-
medicate are discussed.
The group decide that Mrs FH can initially use a diary or calendar for recording her doses of medicines,
and the Sunnybanks nurse can help her and monitor the process. The pharmacist has already discussed
this with Mrs FH, and she agrees that it would help her to take her tablets regularly. Mrs FH would like to
continue to manage them herself, and the group agrees that this is an important part of maintaining a level
of independence. Dr VG agrees to promptly tell Sunnybanks staff of any changes to Mrs FHs medicines.
The team proposes a medication management plan that will be discussed with Mrs FH.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 129
Discussion points
What are the benefits of holding a case conference?
What other information could have been discussed?
What other tools are available to facilitate collaboration between health professionals?
What were the barriers to adherence to medicines in this case?
How could the adherence issue have been resolved using a different strategy?
Did this patients level of care need review?
What are the roles of the various health professionals in resolving this adherence to medicines issue?
The GP:
arranges more frequent testing of the INR initially, as improved adherence may result in change in the INR
reviews timing of the INR test
monitors Mrs FHs cognitive state, for example, mini-mental state examination
assesses pain management
discusses with the supplying pharmacist any dose changes, and arranges the supply of any new
prescriptions.
Sunnybanks staff:
monitor Mrs FHs progress with the new arrangement for managing her medicines
arrange hospital follow up.
The pharmacist:
monitors Mrs FHs progress with the arrangement for her medicines management and recommends
alternative strategies, if necessary
gives Mrs FH advice on taking warfarin, as well as other regular medicines.
The practice nurse at Dr VGs practice:
makes a note in Mrs FHs pharmacy record to arrange a follow-up case conference
notifies Sunnybanks staff of any dose changes and arranges the supply of any new prescriptions, if necessary.
130 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
More information and resources
Australian Government Department of Health and Ageing. Comprehensive medical assessment (CMA)
for residents of aged care facilities (Medicare Item 712). Available at: www.health.gov.au/internet/main/
publishing.nsf/Content/1FA6F368D5A74C3BCA256F19003CB13F/$File/CMA%20Proforma%20final.pdf.
Accessed 24 January 2011.
Australian Government Department of Health and Ageing. Medicare Benefits Schedule, Item 903:
Residential medication management review. MBS online. Available at: www9.health.gov.au/mbs/
fullDisplay.cfm?type=item&q=903&qt=item&criteria=903. Accessed 24 January 2011.
Australian Government Department of Health and Ageing. Medicare Benefits Schedule, items
735,739,743,747,750,758. Multidisciplinary case conferences medical practitioner (other than a
specialist or consultant physician). MBS online. Available at: www9.health.gov.au/mbs/search.cfm?q=735
%2C739%2C743%2C747%2C750%2C758&sopt=I. Accessed 24 January 2011.
Australian Pharmaceutical Advisory Council. Assessment of a residents ability to self-administer. Guidelines
for Medication Management in Residential Aged Care Facilities. 3rd edn. Australian Pharmaceutical
Advisory Council, 2002. Appendix E. Available at: www.health.gov.au/internet/main/publishing.nsf/Content/
57005FFD9007A01FCA256F1800468FE6/$File/resguide.pdf. Accessed 24 January 2011.
Pharmaceutical Society of Australia. Dose Administration Aids Service. Guidelines and standards for
pharmacists. Canberra: Pharmaceutical Society of Australia, 2007. Available at: www.psa.org.au/site.
php?id=6166. Accessed 24 January 2011.
Pharmaceutical Society of Australia. Guidelines and standards for the collaborative and pharmacist
residential medication management review (RMMR) program and associated quality use of medicines
(QUM) services, 2006. Available at: www.psa.org.au/site.php?id=1122. Accessed 24 January 2011.
Pharmaceutical Society of Australia. Standard 3: Comprehensive medication review in professional
practice standards, version 3. Pharmaceutical Society of Australia, 2006. Available at: www.psa.org.au/
site.php?id=843. Accessed 24 January 2011.
Royal Australian College of General Practitioners (RACGP). Medical care of older persons in residential
aged care facilities The Silver Book. 4th edn. Melbourne: RACGP, 2006. Available at: www.racgp.org.
au/guidelines/silverbook. Accessed 24 January 2011.
Royal Australian College of General Practitioners. Section 4 Tools. 11 GP RACF case conference record.
Medical care of older persons in residential aged care facilities. 4th edn. 2006 (Silver Book). Available at:
www.racgp.org.au/guidelines/silverbook. Accessed 24 January 2011.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 131
Notes
132 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Case study 4
Learning objectives
After completing this case, you should be able to:
identify intentional non-adherence
apply an active listening approach to elicit causes of non-adherence
implement a collaborative strategy to address intentional non-adherence.
Mrs JK is a retired seamstress, aged 72 years, who lives with her husband. They have lived in the same
suburb for all of their married life, and have four children and six grandchildren. They enjoy meeting
friends down at the local senior citizens club every Friday lunchtime.
Mrs JK calls into her pharmacy to have repeats of her blood pressure medicines (perindopril and
atenolol) dispensed.
As part of the dispensing process, the pharmacist reviews Mrs JKs dispensing history.
Ten weeks ago: perindopril 5 mg/indapamide 1.25 mg, one daily m30
atenolol 50 mg, one daily m30
Eight weeks ago: atorvastatin 20 mg, one daily m30
calcium carbonate 1500 mg, two daily m60
alendronate 70 mg/cholecalciferol 70 g, one tablet once each week m4
Six weeks ago: perindopril 5 mg/indapamide 1.25 mg, one daily m30
atenolol 50 mg, one daily m30
isosorbide mononitrate S/R 60 mg, one daily m30
Four weeks ago: glyceryl trinitrate s/l spray 400 g/dose, 200 doses m1
atorvastatin 20 mg, one daily m30
calcium carbonate 1500 mg, two daily m60
alendronate 70 mg/cholecalciferol 70 g, one tablet once each week m4
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 133
Mrs JK, your scripts are ready. I can see that you started some new tablets for your angina six weeks
ago. How are you going with those?
They didnt suit me at all. The spray is much better for the chest pain.
Thats interesting. Can you tell me why they didnt suit you?
Dr MB put me on them because Ive been having pain more often recently, but they made me feel
awful. Quite honestly, theyre not as good as the spray. I only need one puff of the spray and the pain
goes away.
We have to make sure that you are getting the best out of your medicine, so I would like to ask you a
few more questions. Would that be alright?
The pharmacist takes Mrs K to the counselling area where it is private and they can sit down away from
other customers.
Mrs JK, what exactly did Dr MB tell you about the new tablets?
She said that I should take one every morning and that I wouldnt have to use the spray so much.
Can you explain to me how exactly you took them?
I took them with my other morning tablets. My husband brings me a cup of tea in bed and I take them
all before I get up. The new tablets were awful though, so I only took them for a few days.
Can you tell me exactly how they made you feel?
They made me very dizzy. I was afraid I would fall over. I cant see how that was any good.
Did you mention this to Dr MB when you went back to see her?
Shes been away on holiday and I didnt want to bother the other doctors. I thought I would just keep
using the spray. Ive been using it for years.
I think Dr MB would like you to go back and talk to her. It seems that you have been experiencing a
fairly common side effect of these tablets. We can give you some advice about things you can do to
prevent the dizziness, but perhaps you should talk to Dr MB first. Shall I ring to arrange for you to have
the next available appointment with her?
Yes, if you think I should. I didnt want to bother her.
The pharmacist notes his conversation with Mrs JK and the actions he has taken in her pharmacy
record. He also inserts a reminder to follow up when Mrs JK is next in the pharmacy. This will alert the
pharmacist on duty to talk to her if he happens to be away.
Discussion points
What are the barriers to adherence?
Were the pharmacists actions appropriate?
Should the pharmacist have used any other strategy to address the adherence issue?
134 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Before Mrs JKs appointment, Dr MB reviews her medical record.
Medical history:
angina
hypertension
osteoporosis
Medicines:
perindopril 5 mg/indapamide 1.25 mg, one daily
atenolol 50 mg, daily
atorvastatin 20 mg, daily
aspirin 150 mg, daily
glyceryl trinitrate s/l spray 400 g/dose, one spray s/l at onset of attack. May repeat once if no relief
within five minutes
alendronate 70 mg/cholecalciferol 70 g, once each week
calcium carbonate 1500 mg, two daily
isosorbide mononitrate S/R 60 mg, one daily (started six weeks ago)
She can see that at the last consultation, Mrs JK reported more frequent chest pain and was prescribed
isosorbide mononitrate S/R 60 mg daily. Because Mrs JK has daytime angina, she was instructed to take
the new tablets in the morning.
Dr MB knows that orthostatic hypotension and headache are common side effects of nitrate medicines.
Discussion point
How would you proceed?
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 135
Mrs JK, I can understand that you prefer to use the spray, because it has worked for you in the past, but
because you are having pain more often, we agreed that you should try these tablets to stop the pain
from happening. Do you remember?
Yes, I remember, but I didnt think they would make me feel bad.
Did I explain to you that the tablets work by preventing the angina pain, whereas the spray relieves the
pain once it happens?
Yes, I do remember that now.
Dr MB talks to Mrs JK about the risks of taking isosorbide mononitrate (possible side effects) versus the
benefits expected from the treatment (improved capacity for physical activity).
It sounds as though you have been experiencing a common side effect of these tablets. What did the
pharmacist tell you when he supplied them?
I think I saw a different pharmacist and I cant remember what she said. I never bother to read all the
paper that comes in the box.
If we can help you avoid the dizziness you were experiencing before, would you agree to try again?
From what you told me, it would be better to take the tablets. I suppose I should have another go.
Thats good. I know that you have always been very careful to take your other tablets regularly. I will
explain what you can do to prevent the dizziness.
Dr MB:
explains to Mrs JK that the dizziness could be caused by a sudden fall in blood pressure when getting up
gives Mrs JK strategies to minimise dizziness, for example, gradually getting out of bed, gradually
getting up from sitting
tells Mrs JK that alcohol can lower blood pressure and increase the likelihood of dizziness
reassures Mrs JK that side effects may resolve with continued use of the medicine
reminds Mrs JK that she can speak to her pharmacist if she would like more information about
her medicines.
Mrs JK agrees to take the isosorbide mononitrate 60 mg daily and come back to see Dr MB in two weeks
time, or sooner if she is having any other problems or if her angina occurs more frequently. She agrees to
have the practice nurse ring her in a few days to find out how she is getting on. She also agrees to Dr MB
contacting her pharmacy.
Discussion points
What are the barriers to adherence in this case?
What other strategies could the GP use to address the adherence issue?
Could this situation have been avoided?
What are the risks of health professionals assuming that health information has been provided by
another health professional?
Who is responsible for discussing the possible side effects of medicine?
136 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Dr MB asks Mrs JK to contact the clinic immediately if she is concerned about side effects or other
problems when she starts taking a new medicine. Dr MB asks the practice nurse to call Mrs JK in a few
days to see how she is going with the new tablets.
The practice nurse or Dr MB contacts the pharmacist and asks him to reinforce the messages she has
received from the GP and to further counsel Mrs JK.
The GP:
monitors Mrs JKs progress with the new medicine, and offers an alternative if side effects are
not tolerated.
The pharmacist:
reinforces the information Dr MB gave Mrs JK on how to manage side effects
gives Mrs JK more information and support on the proper use and interactions of long-acting nitrates
records any counselling provided to Mrs JK or communication with other health professionals about Mrs JK.
The practice nurse:
phones Mrs JK and schedules an early appointment if necessary
reminds Mrs JK of her forthcoming appointments
gives Mrs JK an action plan for using her angina medicine.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 137
More information and resources
myDr. Angina treatments. Sydney: UBM Medica Australia, 2008. Available at: www.mydr.com.au/
heart-stroke/angina-treatments. Accessed 24 January 2011.
National Heart Foundation of Australia. Managing my heart health. Melbourne: National Heart
Foundation of Australia, 2007. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/
Managing-my-heart-health.pdf. Accessed 24 January 2011.
National Heart Foundation of Australia. Will you recognise your heart attack? action plan.
Melbourne: National Heart Foundation of Australia, 2009. Available at: www.heartfoundation.org.au/
SiteCollectionDocuments/Heart-Attack-Facts-Information-Sheet.pdf. Accessed 24 January 2011.
Pharmaceutical Society of Australia. Standard 7, Counselling: The pharmacist systematically records
counselling events that they consider clinically important, in Professional Practice Standards Version 3,
Canberra: Pharmaceutical Society of Australia, 2005. Available at: www.psa.org.au/site.php?id=843.
Accessed 24 January 2011.
138 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Case study 5
Learning objectives
After completing this case, you should be able to:
recognise patient health beliefs as potential barriers to optimal adherence to medicines
identify and use appropriate resources and strategies to overcome communication barriers with
patients from non-English-speaking backgrounds
elicit family support to help patients take their medicines
develop an interprofessional strategy to address non-adherence to medicines
recognise potential difficulties when working with culturally and linguistically diverse people.
Mr YZ came to Australia from Macedonia in 1997. He lives with his wife and works for the local council
as a gardener. He and his wife speak very little English, but their daughter lives nearby and always goes
with them when they visit the doctor.
Mr YZ comes into the pharmacy with his daughter, Mrs TW, who gives the pharmacist a prescription for her
father. She tells the pharmacist that she has just taken her father to see Dr SB at the medical centre. She has
noticed that lately her father has less energy to play with his grandchildren and often gets breathless. Mr YZ
had some blood tests, and after seeing the results today, Dr SB prescribed him some new tablets.
Your prescriptions are ready, Mr YZ. If you would like to sit down over here in the counselling area,
I can explain them to you.
Talk my daughter. English no good.
The pharmacist explains to Mrs TW what the medicines are for and how to take them. She goes through
the Consumer Medicine Information (CMI) for each one, and translates the information for her father.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 139
I noticed Mr YZ does not have his other medicine dispensed regularly from us. Perhaps he goes to
another pharmacy?
No, I dont think so. He doesnt always take them. The doctor said I should speak to you about
nicotine replacement. Dad has been smoking ever since I can remember, so I think it is going to be
difficult for him to quit.
I know it is not easy. Is he ready to give up smoking?
He is just thinking about what the doctor told him. Dr SB said it is very important to stop smoking, lose
weight and do more moderate-intensity exercise, even though his work is physical, because of his heart.
I know its not easy, but many people successfully quit with a combination of the right strategies. I will
give you some information to talk about with your dad, and I can certainly help him choose the right
method when he is ready to quit.
The pharmacist tells Mrs TW that because Dr SB has not written any repeats for the new medicines, it is
important for Mr YZ to go back and see him before the medicines are finished in one month.
The pharmacist makes a record of her discussions with Mr YZ and Mrs TW in Mr YZs pharmacy record.
Discussion points
Were the pharmacists actions appropriate in this situation?
What other action could the pharmacist have taken?
Four weeks later, the nurse in Dr SBs practice is checking which patients have missed their appointments.
She sees that Mr YZ was scheduled to see Dr SB two weeks before, but didnt keep his appointment. She
rings Mr YZ and arranges an appointment in a few days.
Before his appointment, Dr SB checks Mr YZs medical record and notes the following.
Age: 62 Medicines:
Height: 173 cm irbesartan 300 mg, one daily
Weight: 92 kg (started one year ago)
Waist circumference: 104 cm hydrochlorothiazide 12.5 mg, daily
Smoker: 1 pack of cigarettes per day for 45 years (started four weeks ago)
simvastatin 20 mg, one daily
Four weeks ago:
(started four weeks ago)
blood pressure (BP) 145/90 mmHg
aspirin 100 mg, one daily
total cholesterol 6.8 mmol/L
(started four weeks ago)
low-density lipoprotein cholesterol
4.95 mmol/L
high-density lipoprotein cholesterol
0.85 mmol/L
triglycerides 2.2 mmol/L
HbA1C normal
140 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Good morning, Mr YZ. I think last time we offered to have a translator for you, but you prefer your
daughter to come with you. Is that right?
Yes. She explain me.
How are you going with the new medicines?
Mrs TW explains that her father has not been taking his medicines regularly. She noticed that there were
many tablets remaining, although the pharmacist had said that they would only last one month.
Dr SB needs to:
explore the reasons for Mr YZ not taking his medicines and find out exactly what the barriers to his
adherence are
find out what Mr YZ understands about why his medicines should be taken.
Discussion points
What questions could the GP ask Mr YZ to find out why he is not taking his medicines?
What are the advantages and disadvantages of using a professional interpreter, rather than a
family member?
What multilingual resources are available to help patients?
How can the problem of limited multilingual resources be overcome?
When asked why her father is not taking his medicines, Mrs TW says she thinks that her father does not
believe so many medicines are necessary, and that he finds cost is a problem because of his limited income.
Dr SB needs to explore Mr YZs health beliefs so that he can address the barriers to adherence.
Dr SB shows Mr YZ the Australian cardiovascular risk tables and explains that because of his high blood
pressure, lipid levels, age and smoking, Mr YZ has a high risk (2529%) of developing cardiovascular
disease in the next five years. He uses the chart to show Mr YZ that by achieving healthy blood pressure
and lipid levels, the risk can be halved. He tells Mr YZ that quitting smoking will reduce his risk even
more, and that by losing weight as well, Mr YZ will better enjoy playing with his grandchildren.
Dr SB explains to Mr YZ the benefits of following his medicine regimen and the consequences of not
doing so in terms of his absolute cardiovascular disease risk. Dr SB also explains that they can minimise
the cost of the medicines by using a fixed-dose combination medicine for blood pressure and a generic
medicine for dyslipidaemia.
He also asks if Mr YZ has considered quitting smoking, to see if he is ready to quit.
Discussion points
How could Mr YZs cardiovascular risk be explained to him?
How would you explain the reasons for taking the prescribed medicines?
How could the benefits of treatment versus the financial cost of the medicine be explained?
What other ways can the cost of medicines be minimised?
How can the GP help Mr YZ to quit smoking?
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 141
142
Australian cardiovascular risk charts
Peoplewithoutdiabetes How to use the risk charts Peoplewithdiabetes
1. Identify the chart relating to the persons sex, diabetes status,
Women Men Women
smoking history and age. The charts should be used for all adults Men
Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker
aged 4574 years (and all Aboriginal and Torres Strait Islander
179* 179* 179* 179*
adults aged 35 years or older) without known history of CVD or
160 Age 160 160 Age 160
6574 already known to be at high risk. 6574
140 140 140 140
120 120 120
2. Within the chart, choose the cell nearest to the persons age, 120
systolic blood pressure (SBP) and total cholesterol (TC):HDL
179* 179* 179* 179*
Age
ratio. For example, the lower left cell contains all non-smokers
Age
160 160 160 160
5564 without diabetes who are 3544 years and have a TC:HDL 5564 ratio
140 140 140 140
of less than 4.5 and a SBP of less than 130 mmHg.
120 120 120 120
179* 179*
3. The colour of the 179
cell* that the person falls into provides their 179*
160 Age 160
5-year absolute cardiovascular
160
risk level (see legend for
Agerisk 160
140 4554 140
who fall exactly on a threshold between
category). People 140 4554 cells 140
Systolicbloodpressure(mmHg)
Systolicbloodpressure(mmHg)
Systolicbloodpressure(mmHg)
are placed in the cell indicating higher risk.
120 120 120 120
Discussion points
What are the barriers to adherence in this case?
What other strategies could the GP have used to address these barriers?
What could the GP have done if this patient was unwilling to undertake ongoing treatment?
What is the advantage of involving family members in this patients ongoing management?
What are the roles of other health professionals in the follow up of this patient?
.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 143
More information and resources
Australian Government Department of Health and Ageing. Every cigarette is doing you damage. Canberra:
Australian Government Department of Health and Ageing, 2010. Available at: www.quitnow.info.au.
Accessed 10 January 2011.
Australian Government Department of Health and Ageing. Smoking Cessation Guidelines for Australian
General Practice. Practice handbook 2004. Canberra: Australian Government Department of Health and
Ageing, 2004. Available at: www.health.gov.au/internet/main/publishing.nsf/Content/6F8B2F83E439599B
CA256F1900045114/$File/smoking_cessation.pdf. Accessed 11 January 2011.
myDr. Quit smoking: 10 tips. Sydney: UBM Medica Australia, 2008. Available at: www.mydr.com.au/
cancer-care/quit-smoking-10-tips. Accessed 24 January 2011.
National Heart Foundation of Australia (Aslani P, Krass I, Bajorek B, Thistlethwaite J, Tofler G on behalf of
the Heart Foundation Pharmaceutical Roundtable). Module 3: Creating concordance and making shared
treatment decisions. In: Improving adherence in cardiovascular care: A toolkit for health professionals.
Melbourne: National Heart Foundation of Australia, 2011.
National Heart Foundation of Australia (Aslani P, Krass I, Bajorek B, Thistlethwaite J, Tofler G on behalf
of the Heart Foundation Pharmaceutical Roundtable). Module 4: Aiding patient self-management in
cardiovascular care. In: Improving adherence in cardiovascular care: A toolkit for health professionals.
Melbourne: National Heart Foundation of Australia, 2011.
National Heart Foundation of Australia. Australian cardiovascular risk charts. Melbourne: National Heart
Foundation of Australia, 2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/aust-
cardiovascular-risk-charts.pdf. Accessed 10 January 2011.
National Prescribing Service. Medimate (translations). Canberra: National Prescribing Service, 2009.
Available at: www.nps.org.au/consumers/tools_and_tips/medimate. Accessed 10 January 2011.
National Prescribing Service. Translated health information about medicines. Canberra: National
Prescribing Service, 2009. Available at: www.nps.org.au/consumers/translated_health_information_
about_medicines. Accessed 10 January 2011.
National Vascular Disease Prevention Alliance. Absolute cardiovascular disease risk assessment. Quick
reference guide for health professionals. Melbourne: National Vascular Disease Prevention Alliance,
2009. Available at: www.heartfoundation.org.au/SiteCollectionDocuments/guidelines-Absolute-risk.pdf.
Accessed 10 January 2011.
NSW Government Multicultural Health Communication Service. Various resources by topic (heart).
Sydney: NSW Government Multicultural Health Communication Service, 2009. Available at:
www.mhcs.health.nsw.gov.au/topics/Heart.html. Accessed 10 January 2011.
Quitline 131 848
The Royal Australian College of General Practitioners. Guidelines for preventive activities in general
practice (the red book). 7th edn, Melbourne: The Royal Australian College of General Practitioners,
2009. Available at: www.racgp.org.au/guidelines/redbook. Accessed 10 January 2011.
Therapeutic Guidelines. Smoking cessation: the 5A framework (revised 2008). In eTG complete
(CD ROM). Melbourne: Therapeutic Guidelines Limited, 2009.
144 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Case study 6
Learning objectives
After completing this case, you should be able to:
recognise the causes of non-adherence
assess barriers to adherence
develop strategies to address non-adherence that are tailored to the patients needs
systematically assess medicine-taking behaviour.
Mr JD is a 66-year-old retired bus driver who lives with his wife. Mr JD went home from hospital six
days ago. His wife had made him go to hospital after what he thought was unusually bad indigestion.
However, hospital staff told Mr JD that he had had a heart attack. Before Mr JD was discharged from
hospital, the pharmacist gave him some medicines and told him what they were for and how to take
them. Mr JD also remembers being told that the new medicines would only last three days and that he
had to make an appointment to see his doctor as soon as he got home. At the hospital, Mr JD saw so
many people and was given so much information that he became confused, which was made worse by
the shock of being told he had had a heart attack.
When Mr JD got home, he took his new medicines as instructed. However, they looked different to the
ones he had taken before and he wasnt sure if he was supposed to stop taking his previous medicines.
Mr JD remembered his general practitioner (GP) and pharmacist telling him it was important to take
his blood pressure and cholesterol tablets regularly, so he kept taking his previous medicines as well as
the new ones. When the new medicines ran out, he wasnt too concerned because he had plenty of his
previous medicines at home. Anyway, he had an appointment with his GP, Dr DP, the next week.
At the medical centre, while waiting to see Dr DP, the practice nurse asked Mr JD to fill in a pre-
consultation questionnaire. The practice nurse explained that this was a new initiative to help the staff
update his details and provide a better service.
Before the consultation, Dr DP reviews Mr JDs notes and the pre-consultation questionnaire.
Age: 66 Medicines:
Height: 178 cm candesartan 16 mg/hydrochlorothiazide
Weight: 88 kg 12.5 mg, one daily
Medical history: atorvastatin 40 mg, one daily
hypertension Last appointment: two months ago
dyslipidaemia
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 145
Dr DP needs to know the circumstance surrounding Mr JDs admission and the treatment plan the
cardiologist proposes for his ongoing management. She asks Mr JD what he understands about his
condition. Dr DP also asks one of the practice staff to contact the hospital and have Mr JDs discharge
summary faxed to her.
Discussion point
How would you proceed with this patient?
Hello, Mr JD. I see that you have been in hospital recently. What happened?
Nora took me to casualty with indigestion and I ended up in the hospital. They did some tests and told
me I had had a heart attack. I was in there a few days. I thought they would have told you.
No. I havent heard from the hospital. When were you discharged?
Last week. They told me to come and see you when I got home, but I didnt make the appointment
until yesterday.
While we are waiting for the hospital to send me your details, can you tell me what changes they made
to your medicines?
I was given some extra ones. The pharmacist came to see me and told me what they were for. I cant
remember exactly what he said. They couldnt have been very important as they only gave me a few of
each. I went on taking my regular ones when I got home.
Are you still taking the new ones?
They ran out a few days ago, but Im still taking my regular ones.
When Dr DP receives Mr JDs discharge summary, she can see that his medicines have been changed to:
perindopril 4 mg, one daily
metoprolol 50 mg, half a tablet twice daily
simvastatin 40 mg, one daily
ezetimibe 10 mg, one daily
aspirin 300 mg, half a tablet daily.
Dr DP can see that Mr JDs medicine regimen is appropriate. She writes a prescription for the new
medicines and explains to Mr JD what they are all for. Dr DP also tells him to stop taking any previous
medicines he still has at home.
Discussion points
What should the GP do next?
What are the barriers to adherence to medicines in this case?
Were the GPs actions appropriate?
How could this situation have been avoided?
Discuss the difficulties with the transition of patients from the hospital to the home environment.
What are the benefits of a pre-consultation questionnaire?
What strategies could the GP use to improve Mr JDs adherence?
146 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Dr DP contacts the hospitals cardiac rehabilitation coordinator to enrol Mr JD in a cardiac
rehabilitation program.
Dr DP tells Mr JD about the cardiac rehabilitation program and his ongoing management. They agree on
a management plan, and Mr JD agrees to make another appointment in two weeks. Dr DP tells him that
the practice nurse can give him more information about his rehabilitation.
On the way home, Mr JD calls into the pharmacy with his new prescription.
Discussion point
What should the pharmacist do?
Mr JD, here are your new tablets. Would you tell me what Dr DP told you about each one?
Discussion point
How would the pharmacist explore Mr JDs understanding?
The pharmacist explores Mr JDs understanding of his medicines and fills in any gaps. He uses the
Consumer Medicine Information (CMI) sheets as a guide, emphasising the relevant points. The pharmacist
also tells Mr JD the best time to take the medicines and how he can fit them into his daily routine. He
gives advice about possible side effects and what Mr JD should do if he experiences any side effects.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 147
I think Dr DP told you that these medicines replace the ones you used to take. Perhaps you would like
to bring any leftover old medicines to the pharmacy so we can safely dispose of them for you?
That would be a good idea. Ill ask Nora to bring them in, and my old repeats too, so I dont get mixed up.
Thats a good idea. We can also help you to make a complete list of all the medicines you are
taking, whether they are prescribed by your doctor or specialist, or are vitamins, herbal medicines or
over-the-counter medicines. You can carry the list with you. It will be useful when you visit doctors,
specialists or the hospital.
That would be terrific.
Now, dont forget to let me know if you have any difficulties taking the new medicines or call me if you
have any questions.
Okay, I will.
Discussion points
Were the pharmacists actions appropriate?
What could the pharmacist have done differently?
What are the advantages of notifying the community pharmacy when a patient is discharged
from hospital?
What are the benefits of a Home Medicines Review (HMR) for patients recently discharged
from hospital?
What are the benefits of a patient carrying a medicines list?
The GP:
arranges regular follow-up appointments with Mr JD
communicates any changes in medicines regimen to the pharmacist.
The pharmacist:
advises Mr JD of possible side effects and how to manage them
gives Mr JD advice on managing his medicines
adds any medicines changes to Mr JDs new MediList and dates it.
The practice nurse:
reminds Mr JD of forthcoming appointments
liaises with a cardiac rehabilitation coordinator
gives Mr JD advice and support post-discharge, and refers him to the GP as required.
148 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia
Tips for time-poor GPs
Reinforce the importance of adhering to a new medicines regimen.
Ask the practice nurse to:
organise cardiac rehabilitation for the patient
give the patient advice on lifestyle changes post-myocardial infarction
contact the hospital to obtain details of the patients discharge summary (an administrative staff
member could also do this).
Ask the pharmacist to:
explain changes in the medicine regimen to the patient
tell the patient about possible side effects and how to minimise them
give the patient strategies to facilitate adherence to medicines.
Ask the patient to make another appointment in the near future when there will be more time to discuss
his/her situation.
Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia 149
Notes
150 Improving adherence in cardiovascular care | 2011 National Heart Foundation of Australia